TEB SINA CHEHR

(4070932 - 6418770)
 CONTRIBUTORS

George A. Bruder, III, DMD John A. Khademi, DDS, MS

Harvard School of Dental Medicine Private Practice
Boston, Massachusetts Durango, Colorado

G. Garo Chalian, DDS, MS, JD Keith V Krell, DDS, MS, MA, FICD, FACD
Private Practice, Endodontics of Colorado LLC Associate Clinical Professor, Department of
Aurora, Colorado Endodontics
The University of Iowa
Ty E. Erickson, DDS, MS College of Dentistry
Assistant Clinical Professor, Department of Iowa City, Iowa;
Endodontics Diplomate, American Board of Endodontics
The University of Iowa
College of Dentistry Frederick R. Liewehr, DDS, MS, FICD
Iowa City, Iowa Director, US Army Endodontic Residency Program
Assistant Clinical Professor, Department of
Debra R. Haselton, DDS Endodontics
Assistant Professor, Department of Family Dentistry Assistant Adjunct Professor, Department of Oral
The University of Iowa Biology and Maxillofacial Pathology
College of Dentistry Medical College of Georgia
Iowa City, Iowa Augusta, Georgia;
Diplomate, American Board of Endodontics
David J. Holtzmann, DMD, MS
Private Practice Phillip J. Lumley, BDS, MSc, PhD, FDSRCPS
Endodontics of Colorado, LLC Department of Dental Prosthetics and Periodontics
Aurora, Colorado University of Birmingham
The Dental School
William T. Johnson, DDS, MS Birmingham, England
Professor, Department of Family Dentistry and Dows
Institute for Dental Research Damien D. Walmsley, BDS, MSc, PhD, FDSRCPS
The University of Iowa Department of Dental Prosthetics and Periodontics
College of Dentistry University of Birmingham
Iowa City, Iowa The Dental School
Birmingham, England
James L. Jostes, DDS, MS
Assistant Clinical Professor, Department of Robert R. White, DMD
Endodontics Director of Postdoctoral Endodontics
The University of Iowa Harvard School of Dental Medicine
College of Dentistry Boston, Massachusetts
Iowa City, Iowa

v

ndodontics is the discipline of dentistry to which
the responsibility for teaching the anatomy, mor-
phology, histology, physiology, and pathology of
the dental pulp and associated periradicular tissues is of-
ten delegated. Beyond an understanding of the basic sci-
ences and their relationship to the dental pulp, the prac-
tice of endodontics requires great manual dexterity and
the application of knowledge from other dental and
medical disciplines. To be successful the endodontist
must (1) integrate diagnostic and treatment planning
skills; (2) apply knowledge of head and neck anatomy
and morphology, pharmacology, microbiology, inflam-
mation and immunology, systemic and oral pathology,
pain, radiology, and biomaterials; (3) develop excep-
tional technical skills and expertise in performing sur-
gical and nonsurgical procedures; and (4) manage a
complex array of clinical problems. This must be ac-
complished in an environment characterized by an un-
precedented increase in the knowledge base and an ex-
plosion in science and technology.
Unlike the "greatest generation" of World War II, to-
day's patients expect to keep their natural dentition for
the duration of their lives. As this dentate population
ages, the demand for dental services will increase, as well
as the complexity of treatment. This has created pressure
on the dental profession to develop methods and mate-
rials to restore teeth that until recently would have been
extracted.
PREFACE
To meet the needs and demands of the public and to
ensure currency, the modern practitioner must be com-
mitted to lifelong learning. This process involves the
transition from learning in a structured academic envi-
ronment directed by experienced faculty and a set cur-
riculum to self-instruction and exposure to new and var-
ied philosophies. Direct benefits of lifelong learning
include an increased knowledge base; the ability to eval-
uate new materials, techniques, and devices; and en-
hanced patient care. Indirect benefits are enthusiasm for
the practice of endodontics, a challenge to continually
improve, increased expectation of success, and confi-
dence in the knowledge that the treatment being pro-
vided is based on sound biologic and scientific principles.
Lifelong learning symbolizes an individual's commitment
to pursue excellence. It is a professional requirement and
an investment in the future.
The purpose of this atlas is to provide the clinician
with current information on common clinical treatment
techniques in the practice of endodontics. Emphasis is
placed on presenting concepts that facilitate the process
of applying existing knowledge to the unique clinical
problems encountered in daily practice. Using a logical
sequential approach, the atlas is designed to be an ad-
junct to the endodontic literature and serve as an educa-
tional resource for the clinician interested in lifelong
learning and the specialty of endodontics.
William T. Johnson
Vii
 ACKNOWLEDGMENTS
hrough knowledge and experience come wis-
dom. With wisdom and a vision we can all con-
tribute to the betterment of society. As Helen
Keller stated "I long to accomplish a great and noble
task, but it is my chief duty to accomplish small tasks as
if they were great and noble." For the majority of us it is
through the daily accomplishments of the common per-
son that history is written. As Thomas Wolfe stated "So,
then, to every man his chance-to every man, regardless
of his birth, his shining golden opportunity-to every
man his right to live, to work, to be himself, to become
whatever his manhood and his vision can combine to
make him-this, seeker, is the promise of America."
In every time and place there are friends and col-
leagues who influence an individual's life and career.
With this in mind I would like to acknowledge the fol-
lowing individuals:
First and foremost, I would like recognize my parents,
Alvah and Gaillard Johnson, for providing me the op-
portunity to fulfill my dreams. Their commitment to
education and public service was a major influence on
my choosing an academic career in dentistry.
I wish to thank Dr. Arne M. Bjorndal for accepting me
into the specialty of endodontics and for serving as a
friend and mentor.
I wish to thank Dr. Edward M. Osetek for teaching that
those individuals who are privileged to participate in
endodontics have obligations to the specialty.
I wish to thank Dr. Richard E. Walton for his commit-
ment to scientific methodology and scholarship.
I wish to thank Dr. Patrick M. Lloyd for his support and
encouragement in the development of this atlas.
I wish to thank the contributors to this atlas who dedi-
cated their expertise, time, and talents to the cause of
bettering the specialty of endodontics and advancing
the oral health care delivered to the public.
And, last but not least, I would like to thank my wife,
Georgia, and my two sons, Aaron and Jarod, for their
support.
ix
TEB SINA CHEHR
(4070932 - 6418770)
 iagnosis and treatment planning are common el-
ements in all disciplines of dentistry. Although
some clinicians may wish to limit their practice
to certain procedures, diagnostic skills are a universal
requirement.
The specialty of endodontics is unique among the den-
tal specialties, requiring the successful clinician to integrate
knowledge of anatomy and morphology, histopathology,
pharmacology, microbiology, inflammation and immunol-
ogy, pathology, pain, radiology, and biomaterials into the
diagnostic and treatment planning process. The endodon-
tist accomplishes this in an atmosphere characterized by
unprecedented change in science and technology.
Although the majority of pulp and periradicular
pathosis is asymptomatic, these disease processes can
produce variable symptoms.' The astute clinician must
be able to differentiate pulpal and periradicular prob-
lems from other pathologic entities .z Orofacial pain pro-
duced by trigeminal neuralgia, cluster headaches, tem-
poral arteritis, atypical facial pain, acute maxillary
sinusitis, cardiogenic jaw pain, herpes zoster, temporo-
mandibular dysfunction (TMD), and facial pain result-
ing from malignant neoplasms may mimic pulpal pain.
Furthermore, disorders such as cysts, periapical cemen-
toosseous dysplasia, fibroosseous lesions, benign and
malignant tumors, and periodontal disease can be con-
fused with periradicular disease.
The development of a systematic approach to pulpal
and periradicular diagnosis is the first step in developing
treatment options and a definitive treatment plan. To en-
sure a correct diagnosis, the clinician must collect an ac-
curate database. This involves obtaining a medical and
dental history, performing a clinical examination and rel-
evant tests, and making and interpreting appropriate ra-
diographs. The process is the same for the asympto-
matic, urgent, or emergent patient.
After the collection of a complete database, the diag-
nostic process requires correlation and interpretation of
the information obtained. The experienced clinician re-
alizes that arriving at a clinical diagnosis is often diffi-
cult because of a lack of sensitive and specific tests. The
discriminating power of a test is defined by its sensitivity
and specificity. Sensitivity is the rate or proportion of
persons with a disease who test positive for it. Specificity
is defined as the proportion of persons without a disease
who nevertheless test positive for it.
In evaluating a patient, the clinician evaluates infor-
mation from the history and clinical findings; this infor-
mation may suggest a clinical diagnosis. This intuitive
pre-test probability plays a significant role in the estab-
lishment of a correct diagnosis. The purpose of clinical
testing is to confirm or exclude the presence of pulpal or
periradicular disease. The clinician must be convinced
that the probability the patient has pathosis exceeds the
threshold for initiating treatment or that the informa-
tion gathered excludes the potential of pulpal and peri-
radicular pathosis. Clinical tests either convince the clin-
ician that the threshold for treatment has been met or
eliminate the possibility that the disease is of pulpal or
periradicular origin. Experience in test result interpreta-
tion is important because pulp tests and radiographic in-
terpretation are not always accurate. The interpretation
and clinical usefulness of these tests depend on preexist-
i ng probability; the result of any test does not confirm a
diagnosis. 3
For example, two patients are evaluated. The first is
a 28-year-old woman who is asymptomatic but exhibits
a large carious lesion associated with her mandibular
right first molar. Clinical examination reveals a draining
sinus tract on the buccal mucosa opposite this tooth, as
well as a periapical radiolucent area. From this informa-
tion the clinician can make a tentative diagnosis of pulp
1
 Color Atlas o f Endodontics
necrosis and chronic periradicular abscess. Pulp testing
reveals that the mandibular right second premolar and
second molar respond to pulp testing, but the first molar
is not responsive. This supports the diagnosis of pulp
necrosis. The second patient is a 75-year-old man who
is also asymptomatic. Examination reveals that he has
all his teeth except the third molars and has no restora-
tions. Radiographic examination indicates incipient
enamel caries on the mesial aspect of the mandibular
right first molar and considerable calcification of the
pulp chambers in the posterior teeth. A tentative diag-
nosis of reversible pulpitis is established. Pulp testing re-
veals that none of the posterior teeth in the quadrant is
responsive. In this case, clinical information and previ-
ous knowledge play a significant role in diagnosis. The
lack of a distinct etiology, the fact that calcified teeth
may not respond to testing, the decreased innervation of
the pulp with age, and the knowledge that pulp tests are
subjective (requiring interpretation by the patient) lead
the practitioner to place less emphasis on test results.
Because spontaneous pulp necrosis does not occur
and inflammatory periradicular pathosis occurs as a se-
quela of pulp necrosis, etiology is a major diagnostic
consideration. Therefore identification of the etiology
should be an important aspect in establishing a diagno-
sis. Although bacterial invasion of the pulp is a major
etiologic category, restorative treatment, traumatic in-
j ury, nonendodontic pathosis, and radiation therapy
should also be considered.
ACQUIRING A DIAGNOSTIC DATABASE
A fundamental principle in establishing a diagnosis is
gathering information relevant to the disease process.
The clinician must complete the database before begin-
ning the interpretive and decision making process. The
database begins with the patient's medical history.
Medical History
Obtaining a comprehensive written medical history is
mandatory and should precede the examination and
treatment of all patients. The medical history provides
i nformation regarding the patient's overall health and
susceptibility to disease and indicates the potential for
adverse reactions to treatment procedures. Information
regarding current medications, allergies, and diseases, as
well as the patient's emotional and psychologic status,
can be assessed as it relates to the clinical problem. This
information is important in diagnosis because the patient
may have a systemic disease with oral manifestations.
Moreover, a systemic disease may present initially as an
oral lesion.
Dental History
The taking of a dental history allows the clinician to
build rapport with the patient and is often more impor-
tant than the examination and testing procedures. The
dental history almost always contributes to the estab-
lishment of a diagnosis.
The dental history should include the chief complaint
and a history of the present illness if the patient has signs
and/or symptoms of disease. The clinician should ques-
tion the patient regarding the inception, location, type,
frequency, intensity, duration, and cause of any pain or
discomfort to develop a differential and definitive diag-
nosis. The process of information gathering may provide
the clinician with a tentative diagnosis and guide the ex-
amination and testing process.
Pain is a complex physiologic and psychologic phe-
nomenon and often cannot be used to differentiate en-
dodontic problems from nonendodontic pathosis. Al-
though most endodontic pathosis is asymptomatic,
pulpal and periradicular pathosis is a leading cause of
oral facial pain . 4 Identifying the source of a patient's pain
may be routine or complex. In cases that are difficult to
diagnose, a complete history and database become even
more important.
Inflammation and pain in the dental pulp are often
difficult to localize and may be referred to a tooth in the
opposing quadrant or to the preauricular region. Pain
i ntensity has been shown to affect the reporting of re-
ferred pain significantly, whereas duration and quality
have little influence on its incidences Vertical referral
patterns are common but not diagnostic because of hor-
izontal overlap.
Information on previous traumatic injury, a previous
pulp cap or "nerve treatment," or a cracked tooth can be
instrumental in a diagnosis. A history of previous pain
from a symptomatic tooth is also an important finding.'
Reviewing entries in the chronologic record of treatment
and viewing historical radiographs of the area are often
helpful practices.
Clinical Examination
Visual inspection of the soft tissues should include an as-
sessment of color, contour, and consistency. Localized
redness, edema, swelling, or a sinus tract can indicate in-
flammatory disease. Examination of the hard structures
may reveal clinical findings such as developmental de-
fects, caries, abrasion, attrition, erosion, defective
restorations, fractured cusps, cracked teeth, and tooth
discoloration (Figure 1-1).
Diagnostic Testing
PULP TESTING. Pulp tests are an assessment of the pa-
tient's response to stimuli and as such are subjective. They
are designed to assess responsiveness and localize symp-
tomatic teeth by reproducing the patient's symptoms. A
positive response to pulp testing does not indicate vitality,
only sensory perception of the stimuli. Pulp testing is es-
sential in establishing a clinical diagnosis. Testing ensures
the identification of the offending tooth or teeth and is
 Chapter One Diagnosis o f Pulpal and Periradicular Pathosis
FIGURE 1-1 A 32-year-old woman presents for treatment of
spontaneous pain that keeps her awake at night. She relates a his-
tory of orthodontics and a frenectomy as an adolescent, as well as
traumatic injury to the maxillary anterior area during a basketball
game. Clinical examination reveals normal-appearing soft tissues,
scar formation consistent with location of the suture placed after
the frenectomy, and discoloration of the maxillary left central in-
cisor, tooth #9.
FIGURE 1-2 C0 2 snow is an excellent method of thermal testing
because it provides a temperature of -50° C and transforms from
a solid to a gaseous state, eliminating the potential for stimulation
of adjacent teeth.
part of the methodology in the differential diagnosis of
diseases of nonodontogenic origin. Electrical and thermal
testing procedures have been shown to produce reliable
results. 6,7
THERMAL TESTING. Thermal sensitivity is a common
chief complaint in pulp pathosis. Testing with hot and
cold identifies the tooth and is instrumental in determin-
ing whether the pulp is normal or inflamed.
Cold testing is usually performed first. Carbon diox-
3
FIGURE 1-3 C0 2 snow application to tooth #9, which is non-
responsive.
FIGURE 1-4 Dichlorodifluoromethane is also an effective
method of cold testing. The material can be sprayed on a cotton
pellet or cotton-tip applicator for use. As with C02 snow, it has no
li quid state.
ide, or C0 2 ( Figures 1-2 and 1-3), ethyl chloride,
dichlorodifluoromethane (Figure 1-4), and ice sticks (Fig-
ure 1-5) are frequently used to apply cold to teeth. These
tests have been shown to be safe and do not cause dam-
age to the pulp 8,9 or enamel.10 Patients should be advised
of the testing method and expected sensations. The test-
ing should begin on a normal "control" tooth (usually of
the same tooth group or type) to educate the patient re-
garding what to expect from the test, determine whether
the test will provoke a response (validating the use of the
4 Color Atlas of Endodontics

FIGURE 1-5 Ice may also be used to assess vitality. However,
because it has a liquid state it may stimulate adjacent teeth. When
i ce is used the most posterior teeth should be tested first.
FIGURE 1-6 When pulp testing with heat, temporary gutta-
percha stopping can be used.The material is heated over an alco-
hol torch and applied to the tooth surface. Petroleum jelly should
be applied to the tooth surface before testing to prevent the tem-
porary stopping from sticking to the tooth surface.

FIGURE 1-7 After applying the petroleum jelly, the clinician can apply the heated temporary stop-
ping. As with C0 2 testing, tooth #9 is nonresponsive.

test), and allow the clinician to observe the patient's re-
action to the stimulus.
Pulpal pain occurs as a result of tissue damage, and
often the response to thermal stimulation is altered. In
the normal pulp, perception of thermal stimulation is
sharp and immediate but disappears with the removal of
the stimulus. This dentinal pain is conducted by myelin-
ated A-delta nerve fibers and is the result of fluid move-
ment in the dentinal tubules (hydrodynamic theory).11
Dentinal pain is a warning sign and does not necessarily
indicate tissue damage. During pulp testing only the
A-delta nerve fibers are stimulated. C nerve fibers do not
respond to thermal or electric pulp testing because of
their high stimulation threshold.12,13
During injury to the pulp tissue, inflammatory medi-
ators are released and the inflammatory process stimu-
lates unmyelinated C nerve fibers, producing pain that is
not well localized. This pain is often spontaneous and is
described as burning and radiating. It begins without
stimulus and frequently alters the patient's lifestyle. Pro-
longed pain after thermal stimulation is often the first in-
dication that irreversible pulp damage has occurred. The
spontaneous, radiating pain that keeps patients awake
or awakens them at night results from C nerve fiber
stimulation and indicates tissue damage and inflamma-
tion. C nerve fiber stimulation is also responsible for re-
ferred pain.
Thermal testing with heat is indicated when a patient
complains of sensitivity to hot food or liquids . 14 It is
performed by applying petroleum jelly to the tooth sur-
face (Figure 1-6) and heating a stick of gutta-percha
temporary stopping in an open flame. As the temporary
 Chapter One Diagnosis of Pulpal and Periradicular Pathosis
FIGURE 1-8 An alternative method of thermal testing involves
i solating individual teeth with a rubber dam and flooding the tooth
with the appropriate hot or cold liquid. This method is especially
useful when a patient complains of thermal sensitivity and tradi-
tional testing does not reproduce the patient's symptoms.
stopping begins to soften, the clinician applies it to the
lubricated tooth surface (Figure 1-7). A dry rubber pro-
phylaxis cup can also be used to generate frictional heat.
A more effective method of heat testing involves isolating
individual teeth with a rubber dam and flooding the
tooth with hot water (Figure 1-8). This method permits
the application of a uniform temperature to each tooth
and replicates the patient's normal activities. The tech-
nique is effective with full coverage restorations and can
also be used with cold testing. Heat testing is the least
valuable pulp test but is essential when the patient com-
plains of sensitivity to heat.
ELECTRIC PULP TESTING. Electric pulp testing stimu-
lates the A-delta nerve fibers. The electric pulp test (EPT)
indicates only whether the pulp is responsive or unre-
sponsive. It does not provide information regarding the
health of the pulp, nor can it differentiate degrees of pulp
pathosis other than to indicate necrosis when no re-
sponse occurs." It is often used to confirm the results of
previous tests. The EPT requires an isolated dry field.
Traditionally the electrode is coated with a conducting
medium, usually toothpaste, and placed on the dry
enamel labial or buccal surface of the tooth to be tested
(Figure 1-9). Evidence indicates that the incisal edge is
the optimal placement site for the electric pulp tester
electrode to determine the lowest response threshold. 16
Contact with metallic restorations is to be avoided. The
Analytical Technology (Analytic Endodontics, Sybron
Dental Specialties, Orange, CA) pulp tester is recom-
mended because it begins at zero current and increases
the current gradually at a rate predetermined by the op-
5
FIGURE 1-9 Electric pulp testing can be used to establish pulp
vitality or confirm non responsiveness. In this case the failure of
tooth #9 to respond confirms the results obtained with thermal
testing.
erator.17 Patients are instructed to place a hand on the
metal handle to begin the test and release the handle
when they perceive a tingling sensation to stop the test.
Having control of the test is reassuring to the patient. As
with other tests, the clinician should test a normal tooth
first to familiarize the patient with the procedure and
sensation.
All pulp tests have a potential for false positive and
false negative results. A false positive can occur when a
tooth with a necrotic pulp nevertheless responds to test-
ing. This can result from stimulation of adjacent teeth or
the attachment apparatus, the response of vital tissue in
a multirooted tooth with pulp necrosis in one or more
canals, and patient interpretation. Furthermore, the clin-
ician must keep in mind that the cell bodies of the neu-
rons innervating the pulp lie in the Gasserian ganglion.
Only the axons enter the pulp, so the nervous tissue can
maintain vitality in a mass of necrotic pulp tissue. Neural
elements have been shown to be more resistant to necro-
sis18 and C nerve fibers can function in a hypoxic envi-
ronment. 19 Finally, pulp tests are not objective and re-
quire the patient to interpret the response, adding
considerable subjectivity.
An example of a false negative in a pulp test is a
tooth with a vital pulp that nevertheless does not re-
spond to stimulation. False negatives can result from
i nadequate contact with the stimulus, tooth calci-
fication, immature apical development, traumatic in-
j ury, and the subjective nature of the tests. They can
also occur in elderly patients who have undergone re-
gressive neural changes and in patients who have taken
analgesics for pain. The neural elements develop after
6 Color Atlas o f Endodontics
FIGURE 1-10 Direct dentinal stimulation is performed to elimi-
nate the possibility of a false negative result with traditional testing.
I n this case no caries or restorations are present, leaving trauma as
the only distinct etiology. Direct dentinal stimulation is employed
when the clinician suspects that a tooth that does not respond is
i n fact vital.
eruption of the tooth ,20 and the aging of the dental
pulp produces structural and neurochemical regressive
changes that affect pulp innervation. 21 Traumatic in-
j ury can damage the neural elements but leave the vas-
cular supply to the tissue intact . 22
DIRECT DENTINAL STIMULATION (TEST CAVITY). The
test cavity is an invasive procedure that is often used to
ensure that a negative response to previous pulp tests
was accurate. Because this test is invasive and requires
removal of tooth structure and/or restorative materials,
it is used primarily to exclude false negative results. The
test can be used in clinical cases in which a tooth does
not respond to cold testing and EPT but lacks a distinct
etiology for necrosis. In such cases direct dentinal stim-
ulation can be used to reveal necrosis or establish
vitality.
Direct dentinal stimulation involves removing enamel
or restorative materials using a high-speed handpiece
without local anesthesia (Figure 1-10). If the tooth is vi-
tal, the patient will experience a sharp, painful response
when dentin is reached. Clinicians must caution patients
that they will feel the sensations of vibration and pres-
sure so that they can interpret the test correctly.
PERCUSSION. As pulp pathosis extends beyond the
tooth into the supporting periodontal tissues and sur-
FIGURE 1-11 Percussion can be performed with digital pres-
sure, a mirror handle, or the Tooth Slooth. If the patient is sympto-
matic and complains of sensitivity to biting pressure, digital pres-
sure may be all that is required to identify the offending tooth. In
other cases, percussion with a mirror handle may be required to
assess the periapical status.
rounding bone, the patient's ability to localize the of-
fending tooth increases. Proprioceptive fibers in the peri-
odontal ligament are stimulated by force applied to the
tooth and produce localized discomfort. Percussion is
performed by applying force on the incisal or occlusal
surface in an axial direction. This can be accomplished
using digital pressure, tapping on the tooth with an in-
strument handle (Figure 1-11), or having the patient bite
on a Tooth Slooth (Professional Results Inc., Laguna
Niguel, CA) or cotton swab.
Although a positive response to percussion can indi-
cate apical periodontitis secondary to pulp pathosis,
other potential etiologies should also be considered. Ten-
derness to percussion can result from a variety of clinical
problems such as a high restoration, traumatic injury,
traumatic occlusion, a cracked tooth, a vertical root frac-
ture, orthodontic treatment, a periodontal abscess, and
maxillary sinusitis.
Clinicians can also use pressure to test for pulpal
pathosis. Pressure can be applied by having the patient
bite on a cotton swab or the Tooth Slooth (Figure 1-12),
a device that permits the application of force to individ-
ual cusps and can be of value in the diagnosis of frac-
tured or cracked teeth.
PALPATION. As periradicular inflammation extends
through the cortical bone into the soft tissues, it can fre-
 Chapter One Diagnosis o f Pulpal and Periradicular Pathosis 7

FIGURE 1-12 The Tooth Slooth can be used to assess cracked FIGURE 1-13 Palpation of the buccal and lingual soft tissues
teeth and incomplete cuspal fractures. The unique design allows can detect areas of sensitivity and swelling, as well as determine
the patient to exert pressure on individual cusps. the character of the swelling.

FIGURE 1-14 A limited periodontal assessment can be obtained by circumferential periodontal

probing of the area. Often an isolated defect can be identified that is not otherwise apparent in the
clinical and radiographic assessment.

quently be detected by digital palpation of the soft tis-
sues over the apex of the root (Figure 1-13). When the
mucoperiosteum is inflamed, the clinician will detect sen-
sitivity in the involved area. As the inflammatory process
progresses the operator may detect swelling of the soft
tissues. The clinician should note the consistency of any
swelling because not all swelling is the result of inflam-
matory disease. Palpation is not restricted to intraoral
tissues. For example, palpation of extraoral structures
can reveal lymphadenopathy.
MOBILITY. Tooth mobility can be assessed by moving
the tooth in a facial or buccal-lingual direction. Mobility
can be assessed by placing an index finger on the lingual
surface and applying lateral force with an instrument
handle from the buccal surface. The Miller Index of
Tooth Mobility is commonly used to interpret the clini-
cal findings.23 Class '1 is the first distinguishable sign of
greater-than-normal movement, Class 2 is movement of
the crown as much as 1 mm in any direction, and Class
3 is movement of the crown more than 1 mm in any di-
rection and/or vertical depression or rotation of the
crown in its socket. Common causes of tooth mobility
include periodontal disease, bruxism, clenching, trau-
matic occlusion, improper partial denture design, root
fractures, and periradicular inflammation caused by pulp
necrosis.
PERIODONTAL PROBING. Examination of the periodon-
tal tissues is an essential component of the diagnostic
process. Endodontic and periodontic lesions may mimic
each other or occur concurrently. Because periodontal
bone loss may not be detected radiographically and the
gingival tissues may appear normal, probing is required
( Figure 1-14). Keeping a record of the probing depths
aids in determining the patient's periodontal health and
8 Color Atlas o f Endodontics

SELECTIVE ANESTHESIA/ANESTHETIC TEST. Because pain of

pulpal origin is not referred beyond the midline, the
administration of local anesthesia can help localize pain
to a specific area in cases where patients exhibit referred
pain that cannot be localized by the patient or by test-
ing. Administration of a mandibular inferior alveolar
nerve block will determine whether the pain is from the
maxillary or mandibular teeth on the affected side. The
pain will cease if it is from a mandibular tooth and
persist if it is from a maxillary tooth. Although some
clinicians feel that pain from an individual tooth can
be isolated by administering local anesthetic with a
periodontal ligament (PDL) injection, evidence suggests
that this is inappropriate. PDL injections have been
shown to anesthetize teeth adjacent to the tooth being
anesthetized.25

CARIES EXCAVATION. Caries excavation is a frequently

FIGURE 1-15 Transillumination is employed to evaluate teeth for
fracture lines.
prognosis, and the pattern of probing also provides
important information. To obtain adequate information
when examining a specific tooth, the clinician should
probe the entire circumference. Often a narrow probing
defect can be detected with normal sulcular depths im-
mediately adjacent to the defect. Common etiologies for
isolated probing defects include periodontal disease,
periapical pathosis forming a sinus-like trap through the
periodontium, developmental defects such as a vertical
groove defect, cracked teeth and vertical root fractures,
and external root resorption.
TRANSILLUMINATION/DYE STAINING. The use of a fiber-
optic light (Figure 1-15) is an excellent method o£ exam-
ining teeth for coronal cracks and vertical root frac-
tures. 24 The tooth or root should be examined in the
presence of minimal background lighting. The fiberoptic
light is then placed on the varied surfaces of the coronal
tooth structure or on the root after flap reflection. Frac-
ture lines can be visually detected when light fails to tra-
verse the fracture line. The fractured segment near the
light appears brighter than the segment away from the
light.
Application of dyes to the tooth can also demonstrate
fractures as the dye penetrates the fracture line. An an-
cillary technique is the application of dye to the internal
surfaces of a cavity preparation or access opening; the
clinician leaves the dye in place for a week before reex-
amining the tooth.
used procedure to assess pulpal status. In patients ex-
hibiting moderate to severe decay and normal responses
to pulp testing, the clinician must remove the caries be-
fore deciding on a pulpal diagnosis. The initial response
of the pulp to caries is chronic inflammation consisting
of plasma cells and lymphocytes. This is a specific im-
mune response to antigens leaching through the tubules.
Excavation of caries and placement of a restoration re-
move the irritants and establish an environment for heal-
ing. As the dental pulp is exposed and bacteria invade,
the existing chronic inflammatory response becomes
acute as the host responds with polymorphonuclear
leukocytes. This acute nonspecific inflammatory re-
sponse results in the release of lysosomal enzymes and
the destruction of host tissue as well as the invading bac-
teria. This is the crossover point from reversible to irre-
versible pulpitis. 26
Radiographic Examination
Radiographic examination of the hard tissues can often
provide valuable information regarding caries and exist-
ing restorations, calcifications, internal and external re-
sorptions, tooth and pulpal morphology, root fractures,
the relationship of anatomic structures, and the archi-
tecture of the osseous tissues (Figure 1-16). In addition,
radiographs can be used to trace sinus tracts ,27 demon-
strate periodontal defects, and diagnose resorptive le-
sions (Figure 1-17). However, they do have many limita-
tions and are of little value in assessing pulpal status.
Vital and necrotic pulps cast the same image. Moreover,
radiographs are only two-dimensional images of three-
dimensional structures.
Because radiography and some other imaging meth-
ods require ionizing radiation, during the clinical exam-
ination the clinician must prescribe the projection that
will provide the most information at the lowest dose re-
garding the patient's problem. In most cases this is a peri-
apical film or image, although bite-wing and extraoral
films may be necessary.
 Chapter One Diagnosis of Pulpal and Periradicular Pathosis
FIGURE 1-16 Radiographic examination generally requires a peri-
apical projection, although bite-wings and pantomographic projec-
tions are often useful. In this case the periradicular tissues appear
normal; however, a comparison of the root canal space of #8 and
#9 reveals that the space i n tooth #9 is considerably larger. This is
consistent with the clinical presentation, symptoms, and diagnostic
testing results, which indicate necrosis.The radiographic appearance
of the root canal system is caused by the lack of secondary dentin
formation overtime.
Periapical radiographs and other images should be
exposed using a positioning device and a paralleling
technique. This provides the most distortion-free image
and accurate diagnostic information. Although great em-
phasis is often placed on the radiographic examination,
it is an imperfect diagnostic aid because of the varied
techniques and methods for obtaining the film or image
and the variable ability of practitioners to interpret the
information correctly. 28-3 0 Subtle and moderate changes
are often difficult to detect early in the pulpal and peri-
radicular disease process. As the disease progresses, le-
sions become more distinct and easier to detect. Evidence
suggests that a periapical lesion must erode the cortical
plate to be visible on the film or image. 31 Making a sec-
ond film using an angled projection can increase the di-
agnostic accuracy. 322
Periradicular lesions resulting from pulp necrosis have
a characteristic appearance. The radiolucency exhibits a
"hanging drop" appearance, with the lesion beginning on
the lateral osseous surfaces of the root and extending api-
cally into the osseous tissues. The lamina dura is absent,
and the lesion does not move when angled films are taken.
In general, a radiolucent lesion associated with a tooth
with a vital pulp is not of endodontic origin.
9
FIGURE 1-17 Radiographs are useful in diagnosis. External re-
sorptive defects such as the one depicted in the maxillary left cen-
tral incisor are often irregular, with the root canal coursing through
the lesion. Internal resorption such as that depicted in the maxillary
l eft lateral incisor is often symmetric and exhibits destruction of
the canal wall. In addition, internal resorptive lesions remain cen-
tered on angled radiographs.
Condensing osteitis is a proliferative response of
bone to periradicular inflammation. It is characterized
by a diffuse appearance without distinct borders.
Radiographs and digital images appear to be equal
in their diagnostic ability, although the astute clinician
will use the radiographic examination to confirm the
clinical examination. 28-30
DIAGNOSTIC CATEGORIES
The clinical diagnosis is based on the correlation of infor-
mation. Because the information in the database is often
incomplete or inconsistent, experience and the application
of biologic principles allow for rational assessment.
Pulpal
NORMAL. The category of normal is used for teeth that
are asymptomatic, respond normally to pulp testing, and
are free of caries, deficient restorations, developmental
defects, and cracks. Radiographically the periradicular
tissues appear normal with an intact lamina dura.
REVERSIBLE PULPITIS. The category of reversible pulpitis
is used for teeth that respond normally to pulp testing.
10 Color Atlas o f Endodontics
These teeth may be asymptomatic or have mild to mod-
erate symptoms such as thermal sensitivity, sensitivity to
sweets, pain to tactile stimulation, or pain when chew-
ing. The pain generally subsides with removal of the irri-
tant or stimulus, indicating A-delta nerve fiber activity.
Common etiologies to consider are caries, deficient
restorations, attrition, abrasion, erosion, cracks, or de-
velopmental defects that lead to exposed dentin. Dentinal
hypersensitivity is a form of reversible pulpitis. Treat-
ment may involve caries excavation, placing or replacing
restorations, or sealing the dentin. If symptoms occur af-
ter a treatment procedure such as placement of a restora-
tion or scaling and root planing, time may be required
for symptoms to subside. The periradicular tissues ap-
pear normal.
I RREVERSIBLE PULPITIS. The etiologies for irreversible
pulpitis are the same as those for reversible pulpitis, ex-
cept that the symptoms are more severe and consistent
with C nerve fiber activity. The tooth still responds to
pulp testing. In general, the more intense the pain, the
more likely that the pain is caused by irreversible pulpi-
tis. Continuous or prolonged pain after a thermal stim-
ulus is one of the first indications of irreversible pulpitis.
Spontaneous pain is also associated with the condition.
Pain that keeps the patient awake or awakens him or
her is often indicative of irreversible pulpitis. A painful
response to heat that is relieved by cold is a classic
symptom. Root canal treatment, vital pulp therapy, or
extraction is required. Generally the periradicular tis-
sues appear normal, although in some cases the lamina
dura appears widened or shows evidence of condensing
osteitis.
NECROSIS. The positive response to cold and EPT oc-
curs regardless of pulp status in normal, reversible, and
irreversible pulpitis. Necrotic pulps do not respond.
Teeth with necrotic pulps may or may not exhibit peri-
radicular pathosis. Because teeth with necrotic pulps
may exist within normal periradicular structures, the as-
tute clinician performs pulp testing on all teeth before
initiating restorative treatment. Pulp necrosis has two
forms: dry and liquefactive. Dry necrosis is character-
ized by a root canal system devoid of tissue elements.
This type of necrosis is most likely to produce peri-
radicular pathosis. Liquefactive necrosis is characterized
by pulp tissue with structure but lacking significant vas-
cular elements. Liquefactive necrosis is more likely to
produce symptoms and less likely to produce periradic-
ular pathosis.
Periradicular
NORMAL. The category of normal is used to describe the
periradicular status of teeth that are asymptomatic to per-
cussion or palpation and exhibit normal-appearing os-
seous structures with an intact lamina dura.
ACUTE APICAL PERIODONTITIS. The category of acute
apical periodontitis applies to teeth that exhibit normal
periradicular structures but are painful to percussion be-
cause of the stimulation of proprioceptive fibers. The eti-
ology can be pulp pathosis, but high restorations, trau-
matic occlusion, orthodontic treatment, cracked teeth
and vertical root fractures, periodontal disease, and
maxillary sinusitis may also produce this response.
Treatment depends on the diagnostic findings. If pulp
pathosis is the etiology, pulpectomy followed by root
canal treatment or extraction is the most common treat-
ment option.
CHRONIC APICAL PERIODONTITIS. Chronic apical peri-
odontitis results from pulp necrosis and is characterized
by the development of an asymptomatic periradicular le-
sion at the periapex and at the portal of exit in cases ex-
hibiting lateral canals on the side of the root. Histologi-
cally this lesion is categorized as a granuloma or cyst. Root
canal treatment or extraction are the treatment options.
CHRONIC PERIRADICULAR ABSCESS. Chronic periradic-
ular abscess is similar to chronic apical periodontitis ex-
cept that it is characterized by the presence of a draining
sinus tract. The lesion is asymptomatic with an intermit-
tent discharge of pus through the sinus tract. This lesion
is also referred to as chronic suppurative apical peri-
odontitis. Root canal treatment or extraction is required.
ACUTE PERIRADICULAR ABSCESS. Acute periradicular ab-
scess is an inflammatory reaction resulting from pulp
necrosis that is characterized by rapid onset, pain, and ten-
derness to percussion. Evidence of osseous destruction may
or may not be present. A discharge of pus is evident, but
swelling may or may not occur. The exudate can be con-
fined to the alveolar bone, cause localized swelling of soft
tissue, or extend into fascial spaces (cellulitis). The exacer-
bation of a previously asymptomatic chronic apical peri-
odontitis has been termed a phoenix abscess.
The primary method of treating an acute periradicular
abscess is to remove the irritants and provide drainage.
This can be accomplished by initiating root canal treat-
ment and debriding the radicular space or extracting the
tooth. Antibiotics are not a substitute for definitive treat-
ment procedures designed to remove the necrotic tissue
and bacteria from the radicular space. Drainage can be
accomplished through the tooth or through an incision of
the involved soft tissues. This procedure relieves pressure,
increases vascular flow, and evacuates the purulent exu-
date. In these cases, antibiotics serve a supportive role as
adjuvants to treatment. Clinicians should prescribe an-
tibiotics to medically compromised patients and patients
with an increased temperature and systemic involvement.
CONDENSING OSTEITIS. Condensing osteitis is a prolif-
erative inflammatory response to an irritant. The lesion
 Chapter One Diagnosis o f Pulpal and Periradicular Patbosis
is generally asymptomatic and is characterized radio-
graphically by an increase in radiopacity.
SUMMARY
Clinicians must be knowledgeable and skilled in the
process of diagnosis and treatment planning. They
should be able to recognize that the patient has a prob-
lem, identify the etiology, establish a pulpal and peri-
radicular diagnosis, and develop methods of treatment.
Consultation with medical and dental specialists is often
necessary during this process.
Pulpal and periradicular pathosis are inflammatory in
nature. The accuracy of the clinical diagnosis is confirmed
by resolution of the patient's signs and symptoms and heal-
ing of the involved tissues. Therefore periodic recall ex-
amination is an important part of the diagnostic process.
References
1. Bender IB: Pulpal pain diagnosis-a review, J Endodon 26:175,
2000.
2. Okeson JP, Falace DA: Nonodontogenic toothache, Dent Clin
North Am 41:367, 1997.
3. Chang P: Evaluating imaging test performance: an introduction to
Bayesian analysis for urologists, Monogr Urology 12:18, 1991.
4. Lipton JA, Ship JA, Larach-Robinson D: Estimated prevalence and
distribution of reported orofacial pain in the United States, J Am
Dent Assoc 124:115, 1993.
5. Falace DA, Reid K, Rayens MK: The influence of deep (odonto-
genic) pain intensity, quality, and duration on the incidence and
characteristics of referred orofacial pain, J Orofac Pain 10:232,
1996.
6. Georgopoulou M, Kerani M: The reliability of electrical and ther-
mal pulp tests. A clinical study, Stomatologia 46:317, 1989.
7. Peters DD, Baumgartner JC, Lorton L: Adult pulpal diagnosis. 1.
Evaluation of the positive and negative responses to cold and elec-
trical pulp tests, J Endodon 20:506, 1994.
8. Rickoff B et al: Effects of thermal vitality tests on human dental
pulp, J Endodon 14:482, 1988.
9. Dummer PM, Tanner M, McCarthy JP: A laboratory study of four
electric pulp testers, Inter Endo.J 19:161, 1986.
10. Peters DD, Mader CL, Donnelly JC: Evaluation of the effects of
carbon dioxide used as a pulpal test. 3. In vivo effect on human
enamel, J Endodon 12:13, 1986.
11. Ahlquist M et al: Dental pain evoked by hydrostatic pressures ap-
plied to exposed dentin in man: a test of the hydrodynamic theory
of dentin sensitivity, J Endodon 20:130, 1994.
12. Narhi MV et al: The neurophysiological basis and the role of in-
flammatory reactions in dentine hypersensitivity, Arch Oral Biol
39(suppl):23S, 1994.
11
13. Hirvonen T, Narhi MV, Hakumaki MO: The excitability of dog
pulp nerves in relation to the condition of dentin surface, J En-
dodon 10:294, 1984.
14. Rosenberg RJ: Using heat to assess pulp inflammation, J Am Dent
Assoc 122(2):77, 1991.
15. Lado EA, Richmond AF, Marks RG: Reliability and validity of a
digital pulp tester as a test standard for measuring sensory per-
ception, J Endodon 14:352, 1988.
16. Bender IB et al: The optimum placement-site of the electrode in
electric pulp testing of the 12 anterior teeth, J Am Dent Assoc
118:305, 1989.
17. Kleier DJ, Sexton JR, Averbach RE: Electronic and clinical com-
parison of pulp testers, J Dent Res 61:1413, 1982.
18. Torneck CD: Changes in the fine structure of the human dental
pulp subsequent to carious exposure, J Oral Pathol 6:82, 1977.
19. Narhi MV et al: Role of intradental A- and C-type nerve fibres in
dental pain mechanisms, Proc Finn Dent Soc 88(suppl 1):507,
1992.
20. Johnsen DC, Karlsson UL: Development of neural elements in api-
cal portions of cat primary and permanent incisor pulps, Anat Rec
189:29,1977.
21. Fried K: Aging of the dental pulp involves structural and neuro-
chemical regressive changes in the innervation of the pulp, Proc
Finn Dent Soc 88:517, 1992.
22. Bhaskar SN, Rappaport HM: Dental vitality tests and pulp status,
J Am Dent Assoc 86:409, 1973.
23. Miller SC: Textbook of periodontia, ed 3, Philadelphia, 1950,
Blackstone.
24. Schindler WG, Walker WA, III: Transillumination of the beveled
root surface: an aid to periradicular surgery, J Endodon 20:408,
1994.
25. D'Souza JE, Walton RE, Peterson LC: Periodontal ligament injec-
tion: an evaluation of the extent of anesthesia and postinjection
discomfort, J Am Dent Assoc 114:341, 1987.
26. Trowbridge HO: Pathogenesis of pulpitis resulting from dental
caries, J Endodon 7:52, 1981.
27. Bonness BW, Taintor JF: The ectopic sinus tract: report of cases,
J Endodon 6:614, 1980.
28. Goldman M, Pearson AH, Darzenta N: Reliability of radiographic
interpretations, Oral Surg Oral Med Oral Patbol Oral Radiol En-
dod 38:287, 1974.
29. Gelfand M, Sunderman EJ, Goldman M: Reliability of radio-
graphical interpretations, J Endodon 9:71, 1983.
30. Holtzmann DJ et al: Storage phosphor based computed radiogra-
phy versus film based radiography in detection of pathologic peri-
radicular bone loss in a cadaver model: an ROC study Oral Surg
Oral Med Oral Patbol Oral Radiol Endod 86:90, 1998.
31. Bender IB: Factors influencing the radiographic appearance of
bony lesions, J Endodon 23:5, 1997.
32. Brynolf 1: Roentgenologic periapical diagnosis. One, two or more
roentgenograms? Swed Dent J 63:345, 1970.
TEB SINA CHEHR
(4070932 - 6418770)
14 Color Atlas o f Endodontics
A great deal of frustration that many practitioners
have with endodontic treatment stems from the difficulty
of placing a 25-mm instrument in the mesiobuccal (MB)
canal of a distally inclined maxillary second molar. Cor-
rect access design and straight-line access to facilitate in-
strument placement can greatly reduce frustration and
dramatically decrease treatment time.
With the advent of hyperflexible NiTi instruments,
clinicians might mistakenly conclude that minimizing in-
strument flexure is of lesser importance. In fact, straight-
line access and minimizing of instrument flexure is of in-
creased importance in the use of NiTi instruments.
Conventional stainless steel files can be precurved and
"hooked" into canals. If a rotary NiTi file is curved or
bent, it is ruined and must be discarded. In addition,
straight-line access and reduced instrument flexure im-
prove the clinician's ability to use the instruments as
feeler gauges and improve control over the instruments'
cutting action.
Specialists are often referred cases in which the gen-
eral practitioner cannot find the canals. Most of the time
the canals are in the chamber, but the access preparation
precludes the practitioner from locating the canals. The
problem is usually too small an access preparation with
i mproper location and suboptimal shape. After the ac-
cess has been reshaped, the canals are easily located. This
is of particular importance with posterior teeth whose
canals can be easily missed, leading to periapical patho-
sis or continued symptoms.
Unroo fing the Chamber
Unroofing the chamber and removing the coronal pulp
facilitates the clinician's ability to visualize the chamber
floor and aids in locating the canals. Complete removal
of tissue and debris prevents discoloration and subse-
quent infection.
Unroofing the chamber and removing the coronal
pulp (in vital cases) allow the clinician to see the pulpal
floor. In cases of patent canals, most or all of the canal
orifices may be easily located before the chamber is com-
pletely unroofed, but the clinician may nevertheless miss
canals. In cases of calcification, performing these proce-
dures increases the clinician's ability to visualize the pul-
pal floor and read the road map to the canal orifices de-
tailed in the subtle color changes and patterns of
calcification left by the receding pulp. This is extremely
difficult or impossible to do through a "mouse hole" en-dodontic access.
Removal o f the Coronal Pulp
Removal of the coronal pulp so that the canals may be lo-
cated is necessary in cases with vital pulp. One advantage
of removing the coronal pulp is that the radicular frag-
ments may hemorrhage slightly, aiding in location of the
canal orifices. This is especially useful in maxillary molar
cases for locating the second mesiobuccal (MB 2) canal.
Facilitation o f Instrument Placement
Although contemporary endodontic techniques require
fewer instruments, the overall thrust of endodontic clean-
ing and shaping continues to be the serial placement into
the root canal system of variably sized, tapered, or
shaped instruments. This serial placement of instruments
is greatly facilitated by spending a few extra minutes on
the access preparation. Access preparation becomes even
more important with the use of rotary NiTi instruments.
Placement of these instruments requires considerably
more attention to gaining straight-line access.
With the use of traditional stainless steel hand files,
the clinician has several advantages in instrument place-
ment over rotary NiTi instruments. First, the stainless
steel files may be pre-bent, allowing the clinician to hook
the file into difficult-to-access canals. As stated before, a
bent NITI rotary instrument is a discarded NiTi rotary
instrument. Second, the stiffness of stainless steel pro-
vides the clinician with tactile feedback that can be used
to drop the file through the orifice into the canal. The
thin, flexible tips of the NiTi files impair the clinician's
ability to feel obstacles and obstructions and locate the
canal orifice. Further compounding this lack of tactile
sensitivity, the NiTi files are used with a handpiece,
which greatly decreases the tactile sensation of the sensi-
tive and delicate pads of the fingertips.
Coronal and orifice access should act as a funnel to
guide the instruments into the canal. Ideally, the line an-
gles of the access preparation should smoothly guide the
instrument into the correct canal. This funnel shape also
facilitates the introduction of obturation instruments.
Minimizing o f Instrument Flexure
With the greater emphasis on more conservative radicu-
lar shapes and the concomitant use of rotary NiTi files,
the minimizing of instrument flexure has taken on a new
i mportance. Two obvious reasons for reducing instru-
ment flexure are to combat work hardening and decrease
the stresses that the instruments undergo during prepa-
ration of the root canal system. This decreases fracture
incidence and allows more of the energy applied to the
instrument to be used for carving the preparation out of
the radicular walls.
Locating Canals
With complete eradication of the radicular contents, ob-
turation of the radicular space, and good coronal seal to
prevent ingress of bacteria, endodontic treatment should
approach 100% success. However, this does not occur
in reality. The second most common error in access, one
that is often not noticed until a recall film is taken or the
patient complains of persistent symptoms, is missed
canals. The greatest teacher of endodontic anatomy is
the microscope. Clinicians have learned that all roots
( not teeth) with the exception of #6 through #11 may
have two or more canals .z The MB 2 canal of the maxil-
 Chapter Two Endodontic Access
lary first molar is commonly referred to as an "extra"
canal, but this is not the case-the fifth and sixth canals
are the "extras." Without obtaining adequate access in
shape, size, and location, locating the exceedingly com-
plex anatomy present in posterior teeth becomes an ex-
ercise in futility.
Many of these canals are hidden under dentin shelves,
pulp stones, protrusions, and restorative materials. Suc-
cessful treatment requires adequate access, knowledge of
the radicular anatomy, determination, and the assump-
tion of two canals per root until proven otherwise.
I NSTRUMENTS AND ARMAMENTARIUM
The endodontic tray setup should contain an assortment
of round and fissure burs, tapered and round diamonds,
and (for the adventurous) Mueller burs and ultrasonics.
A sharp endodontic explorer is essential. Although they
are often helpful in locating canals, hand files are gener-
ally not used during the access preparation.
Fissure Burs
in an uncrowned tooth exhibiting a patent canal, initial
access is best accomplished by round or fissure carbide
burs (Figure 2-1). Fissure burs such as the #558 produce
less "chatter" when penetrating intact enamel or dentin
FIGURE 2-1 From left to right, a #558 surgical length fissure bur
followed by #1, #2, #4, #6, and #8 surgical length carbides.These
are primarily used for cutting through natural tooth structure.
15
compared with round carbide burs. In contrast, round
carbide burs such as the #6 or #8 seem to be more con-
trollable during the removal of carious dentin.
Round Diamond Burs
New round diamond burs in #4 and #6 sizes work pre-
dictably and quickly to cut through both porcelain-
fused-to-metal (PFM) crowns and the new all-porcelain
crowns (Figure 2-2). The clinician should use relatively
new diamonds with abundant water and intermittent
light pressure to avoid generating excessive heat. If dull
diamonds are used, especially without water coolant, the
clinician may be tempted to apply excessive pressure to
accelerate the cutting process and thereby overheat the
crown. This can result in craze lines and fractures, which
may chip off during instrumentation (when they are easy
to repair) or after treatment completion (when they are
not). After removing the porcelain layer of the PFM, the
clinician can then use a carbide fissure bur or specially
designed metal cutting bur to perforate the metal sub-
structure and underlying foundation.
Tapered Diamonds
Flame-shaped and round-ended tapered crown-prepa-
ration style diamonds are excellent for endodontic ac-
cess (Figure 2-3). They are unequaled for cutting with
FIGURE 2-2 From left to right, round diamonds in sizes #4, #6,
#8, and #10. Used with copious water and a very light touch, they
can predictably and effortlessly cut through PFM and all-porcelain
crowns without fracture.
16 Color Atlas of Endodontics

structures of PFM crowns (Figure 2-4). The additional

expense of using one or two new penetrating burs as
opposed to numerous regular carbide fissure burs is
offset by the time savings and reduced frustration.
Because of the difficulty in cutting through many
restorative materials, especially nonprecious materials,
the clinician is often tempted to shortchange the access
preparation. Having an arsenal of sharp, new burs spe-
cially designed to penetrate these materials helps keep
frustration to a minimum.

Surgical Length Burs

Surgical length burs permit displacement of the hand-
piece away from the incisal or occlusal surface of the
tooth, greatly increasing visibility of the cutting tip of the
instrument (see Figures 2-1 and 2-4, C). With technical
skill, practice, and patience, the clinician can use surgical
length burs to gain access in the majority of teeth, in-
cluding maxillary second molars. Surgical length burs
are often useful in teeth that present the greatest prob-
lems with access and visibility.

FIGURE 2-3 Coarse grit flame-shaped diamonds and a few sizes
of tapered round-ended diamonds can work wonders for refining
access outlines and blending canal orifices. These diamonds can
safely cut natural and decayed tooth structure, precious and non-
precious crowns, PFM crowns, and all-porcelain crowns.
control, predictability, and ease; this is one reason they
are used for the most delicate crown preparations. Per-
haps their use should not be restricted to providing
restorative treatment. Crown-preparation style dia-
monds seem to come in more sizes and shapes than any
other bur.
After the initial penetration into the pulp chamber
has been accomplished, many clinicians advise using a
round carbide to finish unroofing the chamber. Although
this technique may work in some cases, it is very diffi-
cult to perform, especially on a tooth with a small ac-
cess. The result of this technique is often an overpre-
pared, uneven, gouged wall that catches the tips of files
and hampers the placement of files. A much better and
safer option is to use an appropriately sized tapered dia-
mond to open and flare the access. The long cutting sur-
face of the diamond can simultaneously open the cavo-
surface of the access and smooth irregularities in the
access walls. The tip removes the last tags and remnants
of the chamber roof and blends the dentin from the
cavosurface to the canal orifice.
Penetrators and Metal Cutters
Metal cutting burs are highly practical adjuncts for use
with full nonprecious castings and nonprecious sub-
Mueller Burs
Clinicians contemplating tackling difficult or risky cases 3
or those for whom referral is not an option should in-
clude Mueller burs in their armamentaria. Mueller burs
are long-shaft, carbide-tipped burs used in a low-speed
latch handpiece (Figures 2-5 and 2-6). They appear sim-
ilar to Gates Glidden burs, but have a round carbide tip
instead of the noncutting tip of the Gates Glidden bur.
The long shaft is useful for working deep in the radicu-
lar portion of the tooth. In addition, it displaces the
handpiece away from the occlusal surface, allowing the
clinician to see the cutting tip in action. An added bene-
fit of Mueller burs that is not well known even in the en-
dodontic community is that unlike ultrasonics that leave
a ragged, rough, dusty, debris-filled cut, Mueller burs
leave a clean, shiny surface when used on intact dentin.
This surface contrasts well with the "white dot" or
"white line" connective tissue remnant that was left as
the pulp receded. The use of Mueller burs and a micro-
scope makes treating even the most severely calcified
teeth less stressful and more predictable.
Mueller burs (Brasseler USA, Savannah, GA) are used
after the gross coronal access has been achieved and a rea-
sonable but unsuccessful search for the pulp chamber or
canals has been completed. The access preparation is thor-
oughly dried and an appropriately sized Mueller bur is se-
lected. The clinician uses the burs in a brushing motion to
search for white dots or white lines representing the calci-
fied canal. While the clinician cuts, the endodontic assis-
tant uses short, light blasts of air to blow out the dentin
dust, which is then evacuated by high-volume suction. Wa-
ter is not used during the process because color differences
in the dentin that indicate canal location are more evident
in dry dentin. This technique is made even more efficient
with the use of a Stropko irrigator on an air-only syringe.
 Chapter Two Endodontic Access 17

FIGURE 2-4 A, Metal cutting burs are useful for both precious and nonprecious crowns.
Pictured from left to right are the Great White, the Beaver bur, the Transmetal, and the
Brassler H34L.They feature a round-ended, crosscut design that minimizes chatter.They
can also be used to penetrate the metal substructure of PFM crowns. The conventional-
l ength shank also minimizes handpiece bearing load. B, Other burs advocated for en-
dodontic access preparation include the 269GK, the Multipurpose bur, the Endo Z bur,
and the Endo access bur. C, A surgical length #558 bur compared with a regular #558
bur.The surgical length bur enhances visibility by moving the head of the handpiece away
from the tooth. The clinician must exercise care when using extended burs to prevent
perforation. (A and B from Walton RE, Torabinejad M: Principles and practice of en-
dodontics, ed 3, Philadelphia, 2002, WB Saunders.)

FIGURE 2-5 Mueller burs exhibit a long shank and are used in a FIGURE 2-b Mueller burs. The smallest 0.9 mm bur compared
slow-speed, latch-type handpiece. with a #70 file.
18 Color Atlas o f Endodontics

FIGURE 2-7 The Analytic ultrasonic gold nitride tips are available in sizes #2 through #5, and NiTi
tips are available in sizes #6 through #8. Pictured left to right are #2, #3, #6, #7, and #8. Many other
configurations are available.

FIGURE 2-8 The Spartan ultrasonic handpiece has been specifically "tuned" to work the CPR
ti ps.

Because these burs are carbide, they do not endure
sterilization cycles well and become dull quickly. A few
uses are all that can be reasonably expected before they
become dull.
Ultrasonics
The CPR tips are available in nitride (gold-yellow) and
NiTi (green, blue, and purple) (Figure 2-7). The ex-
tremely fine tips coupled with the small handpiece allow
unprecedented visibility (Figure 2-8). Ultrasonic tips can
be used to remove pulp stones and to cut dentin while
locating additional canals.
Canal Orifice Flaring Instruments
An especially important step in preparation for rotary in-
strumentation is flaring of the canal orifice. As discussed
earlier, rotary NiTi instruments cannot be precurved, have
very flexible tips, and produce muted tactile sense because
of the handpiece. Keeping these limitations in mind, the
clinician should spend a few minutes flaring the canal ori-
fices; this technique pays great dividends in increased speed
and decreased frustration. Several instruments are avail-
able to aid in orifice flaring. These include Gates Glidden
drills, GT rotary files (Dentsply Tulsa Dental, Tulsa, OK),
and orifice shapers (Figures 2-9 through 2-11).
 Chapter Two Endodontic Access 19

FIGURE 2-9 Much of the fear associated with Gates Glidden
burs can be mitigated by using the short versions in sizes #4 to
#6. New Gates Glidden drills may tend to be drawn into the canal.
They can be run backward until they are slightly dull.
FIGURE 2-10 This GT rotary file has a #35 tip, 1.25 mm maxi-
mum flute diameter, and a .12 taper. It can be used at up to 700
RPM for orifice flaring. In patent canal cases, it can be used as a
single instrument replacement for the entire set of Gates Glidden
burs or orifice shapers.

FIGURE 2-11 Orifice shapers are 19 mm long and proceed from a #20/.05 taper to #80/.08.
They are used in sequence from left to right to create a funnel within the canal.
20 Color Atlas o f Endodontics

FIGURE 2-12 The operating microscope is an indispensable tool for state-of-the-art endodontic
treatment. The specialty practice should not be without a microscope; this instrument is useful in all
phases of endodontic treatment from diagnosis to placement of the final restoration.

A B

FIGURE 2-13 A, Removal of the amalgam permits inspection of the tooth for fractures. The use
of microscopy allows identification of a mesiodistal fracture. The pulp chamber has not been en-
tered. B, On entering the pulp chamber, the clinician notes a fracture across the pulpal floor from
mesial to distal. Wedging a Glick instrument into the access allows the clinician to visualize the frac-
ture spreading and closing in this hopeless tooth. Although this gross fracture was visible with
l oupes, the extent of many fractures cannot be seen. Diagnosis and prognostication then become
guessing games at best. Note the white dot of the MB 2 canal located (in vain) with a Mueller bur
above the fracture about halfway between the fracture and the MB canal; this was not visible with-
out the microscope.

VISION, MAGNIFICATION, free with microscope use, and previously impossible

AND ILLUMINATION
Although ultrasonic and Mueller bur techniques can be
used without magnification, they are faster, more pre-
dictable, and safer with magnification. The operating mi-
croscope is the greatest teacher of endodontic anatomy 4
( Figure 2-12). Previously difficult cases become stress
cases become routine. With the enhanced vision and il-
lumination of the microscope, the clinician operates in
an entirely different mode-visually.
To become proficient with the microscope, the clini-
cian should not pull it into service on only the most dif-
ficult cases. In fact, without the use of the microscope
the clinician may not even be aware of factors increasing
 Chapter Two Endodontic Access 21

A B

FIGURE 2-14 A, The lingual view shows the incisally repositioned access with the rotary notch.
B, From the lateral view, the darker wedge-shaped portion of the access shows how incisally this
notch may be placed. With the repositioned access, very little cervical dentin needs to be removed.

the difficulty of the case and therefore miss cues only vis- constraints on access design. They are unforgiving of poor
ible with the magnification and illumination the micro- access design, irregularities in the access walls, and poor
scope provides (Figure 2-13). blending of the walls and pulpal floor into the canal orifice.

Maxillary Incisors
UNCOMPLICATED ACCESS PREPARATIONS
Given the goals and constraints of endodontic access, a
distinctive shape is required for each tooth type based
on the most common anatomic features of the crown as
well as the radicular morphology. Maxillary central and
lateral incisors share common coronal and radicular
anatomy, 5,6 as do the maxillary premolar and molar
tooth groups. The same can be said for the mandibular
teeth. Although maxillary and mandibular canine teeth
share common coronal and radicular form, the lack of
two canals in the maxillary canine as well as less fre-
quent lingual inclination result in a somewhat more con-
strained access form in the maxillary canine.
Some degree of attrition occurs in the natural adult
dentition and dictates some changes in endodontic ac-
cess design. Because one of the traditional anatomic
landmarks (the incisal edge) has been lost, the clinician
may be tempted to make the access midway between the
"new" incisal edge and the cervical edge. This results in
an access that is too cervically positioned.
In light of recent changes in the understanding of
canal anatomy, the increased use of rotary NiTi instru-
ments, and the advent of predictable bonding to natural
tooth structure with many of new restorative materials,
the time may be ripe to reconsider current notions of en-
dodontic access design. Any one of these factors alone
might merit rethinking of the access for endodontic
treatment, but taken together, they dictate change.
The use of rotary NiTi instruments places even stricter
In uncomplicated cases, both maxillary central and lat-
eral incisors share a common triangular-shaped access
from the lingual surface of the tooth. The classic access
design places the access centrally on the lingual surface
between the incisal edge and the cervical edge7 ( Figure
2-14). This design is reflective of the poor restorative
choices available in the past as well as the limited op-
tions for "hiding" the access more cervically. Such a de-
sign results in a much larger amount of dentin removal
at the lingual cervical edge to gain straight-line access.
With improved esthetic bonded composites, the classic
access form can be modified by placing it considerably
more incisally (Figure 2-15). The initial penetration
should be approximately in the middle of the lingual
surface of the tooth, not just above the cingulum as has
been previously described.' After locating the canal, the
clinician uses a long, tapered diamond to extend the ac-
cess even further incisally and laterally. An additional
modification for use with rotary instrumentation is to
slightly notch the middle of the incisal extent of the ac-
cess (see Figure 2-15). This allows even better straight-
line access and greatly decreases the potentially cata-
strophic cervical flexure of the rotary instruments that
can contribute to premature, unexplained fracture.
In anterior teeth the clinician must take care to re-
move all the coronal tissue and debris from the cham-
ber. Material left in the chamber can cause tooth discol-
oration. The pulp horns are common locations for
residual tissue (Figure 2-16).
22 Color Atlas of Endodontics

FIGURE 2-15 View of accessed tooth from the incisal and slightly lingual. Note the rotary notch
i n the middle of the incisal extent of the access. This notch allows more straight-line access for ro-
tary NiTi instruments and greatly helps eliminate cervical flexure that can cause "unexplained" in-
strument breakage.

FIGURE 2-16 A, Residual pulp in horn. B, Tapered, round-ended diamond burs are used to remove
debris. The diamond leaves an optimal surface for bonding. C, In immature cases with large pulps,
the clinician must take care to remove all material in the pulp horns. Often a tapered, round-ended
diamond bur can be used to blend the pulp horns into the access form. This blending should be
rechecked before the final restoration because any residual pulpal debris, bacteria, sealer, and gutta-
percha can contribute to subsequent discoloration.
 Chapter Two Endodontic Access 23

FIGURE 2-17 Access opening for the maxillary canine.

A B

FIGURE 2-18 A, Initial access penetration occurs in the middle of the incisal-cervical dimension.
After locating the canal, the clinician extends the access incisally. Note the facial veneer. B, Com-
pleted access from the incisal view.

Maxillary Canines gin" tooth. This modification to access may occur on

In uncomplicated cases the maxillary canine access is
rather broad from buccal to lingual, which reflects the
broad buccolingual shape of the root and the canal space
( Figures 2-17 and 2-18). In the adult dentition the incisal
edge of the maxillary canine has usually undergone sig-
nificant attrition (Figure 2-19). This alters the normal
anatomic landmarks for endodontic access midway be-
tween the cervical bulge and the incisal tip (see Figure 2-
19). Therefore the endodontic access will be located in a
more incisal position than would be the case on a "vir-
any tooth but is most common with the maxillary and
mandibular anterior teeth.
Maxillary Premolars
Although not all maxillary premolars have two canals,'
they should all be approached from the assumption that
they have separate buccal and lingual canals (Figure
2-20). This dictates a broad buccolingual access form that
is somewhat constrained in the mesiodistal dimension (Fig-
ure 2-21). The maxillary premolar access is never round.
24 Color Atlas of Endodontics

FIGURE 2-19 The effect of attrition.This slightly lingual and incisal view of a tooth shows the ac-
cess encroaching on the incisal edge.

A B

FIGURE 2-20 Access for maxillary premolars. A, Buccal view. B, Mesial view. C, Occlusal view.
 Chapter Two Endodontic Access 25

FIGURE 2-21 A, Preoperative view with a distal occlusal (DO) composite. Note the mesial con-
cavity. B, Initial access to the pulp chamber is broad buccolingually and narrow mesiodistally.
C, The cusps are flattened to gain more accurate reference points. D, The diamond is used to blend
the coronal portion of the access with the cervical portion. This blends the buccal and lingual pulp
horns and removes pulp tissue from these areas.
26 Color Atlas o f Endodontics

Maxillary Molars
Treatment of maxillary molars is never routine (Figure
2-22). In a recent study of maxillary first and second
molars an MB 2 canal was found in 96% of the
mesiobuccal roots of maxillary first molars and 94% of
the maxillary second molars. Approximately 54% were
located in the traditional access opening, 31% were
found with the use of a bur, and 10% were found with
the aid of a microscope. The MB Z canal orifice was
found on average 1.82 mm lingual to the main MB
canal orifice. 9 In another study of the maxillary first
molar using microscopy, the MB Z canal was located in
93% of first molars and 60% of second molars 4 (Fig-
ures 2-23 and 2-24). The difficulty in access, high per-
centage of fourth and even fifth canals, and root curva-
tures put even the "routine" maxillary molar in a
high-risk category. 3 Complicating factors such as lim-
ited opening, crowns, changes in tooth angulation,
tooth position, and calcification make predictable treat-
ment of these teeth challenging for even the most expe-
rienced clinician trained in microscopy, ultrasonics, and
rotary instrumentation.
The clinician wishing to treat these high- to extreme-
risk cases should perform a 6-month chart review to de-

FIGURE 2-22 Buccal view of the access for maxillary molars. FIGURE 2-23 An occlusal view of the access for maxillary
molars.

FIGURE 2-24 The location of the MB 2 canal is mesial to the line connecting the MB and palatal
orifice. In the maxillary first molar the MB 2 canal is generally located within the range shown. In the
maxillary second molar the location of the MB 2 is highly variable and can be located from the MB
orifice to the palatal orifice (see Figs. 2-46 and 2-47).
 Chapter Two Endodontic Access 27

termine the percentage of cases with at least four canals.
If the percentage is less than 45% for first molars or less
than 35% for second molars, these cases should be care-
fully screened for referral because the MBZ canal is being
missed and untreated about half of the time.
Guidelines for canal location in the maxillary first
molar (Figure 2-25) differ from that in the maxillary sec-
ond molar. In the maxillary first molar the MB canal is
located under the mesial buccal cusp (see Figure 2-25,
D). The MB Z canal is located mesial to a line from the
MB canal toward the palatal canal (see Figures 2-25, E,
and 2-26). The DB canal is located distal to the MB
canal in the buccal groove area, slightly lingual to the
MB canal (see Figure 2-25, G). The palatal canal is gen-
erally the largest canal and is located under the me-
siolingual (ML) cusp (see Figure 2-25, F). These general
locations remain the same as the pulp calcifies with age
( Figure 2-27). Although these general principles apply to
the maxillary second molar, the chamber may be nar-
rower, resembling a straight line (see Fig. 2-55).

FIGURE 2-25 A, Preoperative photograph of a maxillary molar. The pronounced cervical bulge
over the MB is highly suggestive of a large root and two canals. B, Preoperative radiograph of this
necrotic maxillary first molar. Note the constricted pulp chamber. The angle of entry to the mesial
canals is from the distal. C, The canals have been prepared to help illustrate their locations and an-
gles. Note that in the following illustrations the access form may need to be extended or modified on
the side opposite the canal to clear the rotary instruments and avoid cervical flexure of the instru-
ments. D, The angle of entry into the MB canal is markedly from the distal and palatal. The access
may need to be extended distally and palatally to allow clean placement of instruments.
Continued
28 Color Atlas o f Endodontics

FIGURE 2-25, cont'd E, The entrance into the prepared MB 2 i s

from the distal and slightly from the palatal. The access may need
to be extended distally to allow clean placement of rotary instru-
ments into the MB2 . F, The angle of entry into the palatal is from the
buccal and mesial. Occasionally the access may need to be ex-
tended to the MB to allow clean placement of rotary instruments
i nto the palatal canal. G, The angle of entry into the DB canal is
from the mesial and palatal. A diamond bur (see Figure 2-26) can
be used to relieve the impeding restorative material or tooth struc-
ture. H, The completed case. Note that the access is not in the cen-
ter of the tooth. Adequate access to locate, negotiate, prepare, and
obturate can be obtained without violating the transverse ridge.
Note that the access extends almost to the MB cusp tip. I, The HF-
etched silanated composite crown repair of the endodontic access
is outlined in black. The presence of this type of radicular anatomy
is usually unconfirmed until the case is complete. Missing the MB 2
canal here would doom the case to failure because of the pres-
ence of separate foramina.
 Cbapter Two Endodontic Access 29

FIGURE 2-26 A, On entering the pulp chamber in this maxillary second molar, the clinician can
readily locate the MB2 orifice along a line connecting the MB and palatal orifices.This "false orifice"
is a source of frustration for many dentists because although it can be probed, it is often resistant
to negotiation.The reason for this is that the MB 2 canal proceeds mesially (horizontally) before mak-
i ng a 90-degree turn down the root. B, The prepared and obturated MB 2 canal is considerably more
mesial than the original orifice. The red dot to the distal of the obturated MB2 is the location of the
false original orifice. A technique routinely employed is to notch this area with a tapered round-
tipped diamond, Mueller bur, or Gates Glidden bur to gain straight line access to the MB 2 canal.This
technique is detailed in later figures.

FIGURE 2-27 A, Original view of canal shapes in a 9-year-old's maxillary first molar. Note that
the very broad MB "canal" is full of debris. B, Computer-enhanced view of canal spaces at 9 years.
Continued
30 Color Atlas of Endodontics

C D

FIGURE 2-27, cont'd C, Computer simulation of typical calcific metamorphosis (calcification) in

an adult tooth. D, Computer simulation of significant calcific metamorphosis.

A B

FIGURE 2-28 A, Access for a mandibular incisor as viewed from the lingual. The access is quite
high on the lingual surface of the tooth. This gives the clinician a much straighter shot down the
canal and minimizes the chance of perforating out the facial surface. B, This mesial view shows the
access extending nearly to the incisal edge.

Mandibular Incisors
As with the other anterior teeth the traditional access to
the mandibular incisor was more cervically placed than
necessary because of esthetic constraints. The optimal
access for the mandibular central and lateral incisor is
actually through the incisal edge, but this is balanced
with the desire to maintain an intact incisal edge where
possible (Figure 2-28). In the mature adult tooth, attri-
tion has generally caused the access to extend through
the incisal edge'° (Figure 2-29).
Because two canals are present in about 40% of all
mandibular incisors,11 these teeth should be assumed to
have two canals until substantial evidence to the con-
trary is discovered.
 Chapter Two Endodontic Access 31

FIGURE 2-29 I n this attrited and rotated incisor with two canals,
an incisal access greatly facilitated location of the lingual canal.
FIGURE 2-30 The typical error in access on a mandibular in-
cisor is to perforate toward the facial (white dot). The clinician had
already "located" the canal but bypassed it while continuing to drill
down and to the facial. Mandibular incisors are rarely perforated to
the lingual.

FIGURE 2-31 While searching for a calcified canal, clinicians tend to drill in an apical direction but
neglect to take into account the natural angulation of the mandibular incisor, resulting in buccal
perforation.

Because of the facial inclination of the tooth, per-
foration of the facial aspect of the root is a common
procedural error in accessing mandibular incisors (Fig-
ures 2-30 and 2-31). In cases of rotation or crowding a
facial approach to access should be considered. 12
ally has two canals and therefore requires a broad facial-
lingual access. The access opening is ovoid and located
on the lingual portion of the crown (see Figures 2-32 and
2-33). As wear occurs, the access may involve the incisal
edge (Figure 2-34).

Mandibular Canines Mandibular Premolars

The mandibular canine has a very broad facial-lingual The broad buccolingual dimension of the mandibular
dimension to its root (Figure 2-32). This root occasion- premolar dictates an access form that is about twice as
32 Color Atlas o f Endodontics

FIGURE 2-32 Access openings for the mandibular canine. FIGURE 2-33 An ideal access opening in a mandibular canine.
Viewed from the incisal surface, the access is slightly to the lingual
and can be seen extending to nearly the incisal edge.

A B

FIGURE 2-34 A, Preoperative view of a mandibular canine with incisal attrition. B, Occasionally the
mandibular canine has two canals. A more incisally and facially positioned access facilitates location
of the lingual canal.

broad in the buccolingual dimension than it is mesio-
distally (Figures 2-35 through 2-37). Although most
mandibular premolars have a single canal, two canals
occur about 25% of the time in mandibular first premo-
lars 13; rarely, three canals are present. When numerous
canals are present, the preoperative radiograph often in-
dicates a "fast break." This appears as a relatively patent
canal space in the coronal portion of the tooth that sud-
denly disappears (Figure 2-38). Locating the two canals
requires an appropriate access (Figure 2-39).
 Chapter Two Endodontic Access 33

FIGURE 2-35 Viewed from the occlusal, the access is relatively well centered in the buccolingual
and mesiodistal dimensions. It is about twice as broad buccolingually as it is mesiodistally.

FIGURE 2-36 A, Viewed from the buccal surface, the access is conservative mesiodistally.
B, Viewed from the mesial, the crowns of the mandibular premolars have a slightly lingual inclination
relative to the root.

FIGURE 2-37 Occlusal view of access through a PFM crown.

34 Color Atlas o f Endodontics

FIGURE 2-38 Radiographic appearance of a fast break in the mandibular right first premolar. The
coronal extent of the canal is readily visible but abruptly disappears in the middle of the root, indi-
cating at least two canals. Note that the second premolar has three roots.

FIGURE 2-39 A, The mandibular first pre-

molar has two canals about one quarter of the
ti me. This crown of the mandibular first premo-
l ar can have a marked lingual inclination that
may misdirect the clinician's bur too far to the
buccal. This increases the likelihood of perfo-
ration and greatly decreases the chances of lo-
cating a lingual canal. In this retreatment clini-
cal case, the access error manifests as a small
round access too far to the lingual. B, Extending
the access to the buccal allows the clinician to
l ocate the missed lingual canal (top) and ob-
turate both canals. C, Obturation.
 Chapter Two Endodontic Access 35

Mandibular Molars
The access to the mandibular molars has been presented
by many as triangular in shape. This access shape greatly
hinders the clinician's ability to locate the DB canal when
one is present and to treat the full buccolingual extent
of the broad distal canal when a single distal canal is
present. The naturally present slight mesial and lingual
i nclination of the tooth, coupled with the clinical access
to the tooth, dictates an access that is placed more to-
ward the mesial half of the tooth and may extend buc-
cally to nearly the MB cusp tip (Figure 2-40). The access
may occasionally cross the central pit (Figure 2-41).
In mandibular molars the MB canal lies under the
mesiobuccal cusp tip. The ML canal often appears in line
with the central groove crossing the mesial marginal
ridge. The lingual inclination of the tooth in the arch,
coupled with the lingual constriction of the crown, ac-
counts for this anatomic relationship (see Figure 2-40,
C). The distal canal is generally at the intersection of the
buccal, lingual, and central grooves as viewed from the

FIGURE 2-40 A, Viewed from the occlusal, the access can be seen to just cross the central pit area
and extend to nearly the MB cusp tip. B, Viewed from the buccal, the access is slightly mesially inclined.
C, Viewed from the mesial, the buccal extent of the access can extend to nearly the MB cusp tip.

FIGURE 2-41 The ideal access is demonstrated on this mandibular first molar through a PFM
crown.
36 Color Atlas o f Endodontics

FIGURE 2-42 A, The lingually placed triangular form of this access precluded the clinician from
locating the MB canal and hindered the ability to instrument the buccal extend of the ovoid distal
canal. B, Extending the mesial half of the access to the buccal to nearly the MB cusp tip and ex-
tending the distal half more buccally allowed the MB canal to be located and greatly facilitated
instrumentation.

FIGURE 2-43 A, A common variation of the maxillary first molar-the bowling pin DB. The DB
canal appears similar to an inverted bowling pin. Note the fluting to access the MB 2 . The bowling pin
appearance can result in two separate canals. B, The presence of three MB canals is an additional
variation. In this case the MB2 and MB 3 were confluent, which is not expected given the proximity of
the MB2 to the MB.
 Chapter Two Endodontic Access 37

occlusal surface. When a DB canal is present, it will be Maxillary Second Molars

located to the buccal and often slightly mesial to the
main distal canal (Figure 2-42). The incidence of four
canals is approximately 35% .14
In mandibular second molars a C-shaped canal is a
morphologic variation.15 The incidence of this canal
morphology is approximately 8% (see Figures 2-54 and
4-3). 16
In contrast to the maxillary first molar, the maxillary sec-
ond molar exhibits a variety of root forms. Any two of
the roots can fuse, and occasionally all three of the roots
can fuse. Despite these aberrant root forms, the maxil-
lary second molars can have from one to five canals,
with four canals being the most common (Figures 2-45
through 2-47).

CANAL PATTERNS IN MOLARS

With the increased use of the microscope, several addi-
tional patterns of canals have been identified. Every clin-
ician has seen unusual radicular anatomy and mor-
phology. Instead of showcasing all of these anatomic
anomalies, this section highlights some of the more com-
mon variations.

Maxillary First Molars

Although little variation occurs in the root form of the
maxillary first molar, several internal patterns can belie A
the simplicity of the external surface of the tooth. These
include variations in the mesiobuccal and distobuccal
roots (Figures 2-43 and 2-44).

FIGURE 2-44 This is a relatively uncommon pattern in which one
coronal orifice gives rise a few millimeters down the canal to an
MB and MB 2 . The case complexity is compounded by the presence
of an MB 3 . The maxillary second molar also can have this pattern
of a bifurcation partway down the MB orifice.
FIGURE 2-45 A, Contrary to popular understanding, the most
common pattern in the maxillary second molar is four canals. In
this case the rather large MB 2 i s visible as a red bleeding point.
B, The obturated MB 2 i s just slightly mesial of the line connecting
the MB and palatal canals. In the maxillary second molar the lo-
cation of the M132 varies greatly, but this case shows a more typical
l ocation. Note the fluted access to the mesiobuccal canal.
FIGURE 2-46 There is considerable variation in the location of the MB 2 i n the maxillary second
molar. In this case, it is very close to the MB. It is highly variable in the fused root case. It can also
be found considerably closer to the palatal canal (see Figure 2-47).

FIGURE 2-47 A, Occasionally the MB 2

canal is off the palatal orifice, or even "in"
the palatal orifice.These more unusual loca-
tions (very close to the MB or very close to
the palatal canal) occur more frequently in
fused root cases. B, After obturation. C, In
this fused root case the MB and DB canals
join but the MB 2 has a separate portal of
exit.
 Chapter Two Endodontic Access 39

A B

FIGURE 2-48 A, A single round distal canal occurs less commonly than the "figure 8" or oval dis-
tal variation. B, The most common pattern is two mesial canals with a connecting isthmus and a fig-
ure 8-shaped distal canal. The distal canals usually join but can be separate.

A B

FIGURE 2-49 A, At the orifice level the distal canals appear to be confluent. B, The radiograph
shows they are not.

Mandibular First Molars
The mandibular first molar traditionally has three or
four canals (Figure 2-48), but they are considerably eas-
ier to locate than they are in the maxillary first molar.
The most commonly missed canal is the DB, probably
because the legacy of a triangular access form makes de-
tection of this canal somewhat more difficult. When
more than one canal is present in a root the canals can
exhibit separate portals of exit (Figure 2-49). Five and
six canal variations have been reported in the litera-
ture, l5 but taken together they account for a small per-
centage of the cases (Figures 2-50 and 2-51). As with the
maxillary first molar, root fusion is uncommon in the
mandibular first molars.
form variations. This manifests internally as large varia-
tions in the number and locations of the canals (Figures
2-52 through 2-54). Although the initial access form
should be somewhat trapezoidal, it may need to be ex-
tended to allow more straight-line access for certain
canal configurations.
MANAGING COMPLICATIONS
Rarely is the clinician presented with an unrestored,
caries-free tooth to treat. The following section illus-
trates specific clinical techniques and tips to help the clin-
ician manage more complicated cases and avoid proce-
dural mishaps.

Mandibular Second Molars Existing Restorative Materials

As with the maxillary second molars, mandibular sec- In cases where the access is surrounded by metallic
ond molars have a greatly increased incidence of root restorative materials, the restoration should be removed
40 Color Atlas of Endodontics

A B

FIGURE 2-50 A, The presence of three distal canals is an additional variation. B, The postopera-
tive radiograph.

FIGURE 2-51 Three mesial canals occur in a few variations. This FIGURE 2-52 The other four-canal variation in the mandibula
pattern is rather evenly spaced. Occasionally the mesial middle second molar is three mesial canals.
( MM) is closer to the ML. The MM can also be closer to the MB.

FIGURE 2-53 The fused root variation in the mandibular second molar may have only one mesial
and one distal canal. Occasionally only a single canal occurs.
 Chapter Two Endodontic Access 41

FIGURE 2-54 A, As with the three-rooted mandibular first molar, the C-shaped mandibular sec-
ond molar occurs more commonly in Asian persons and Native Americans. Typically, the C is open
to the lingual, and the ML canal remains somewhat separate. Histologically, this is one large canal
that is usually negotiable in three spots: ML, B, and DL. B, The postoperative radiograph demon-
strates the C configuration.

A B

FIGUict 2-55 A, A band of distal caries and unsupported enamel was left to aid in isolation and
clamp retention in this maxillary second molar. B, Using a caries detector, after obturation the clin-
i cian removed decay and placed a band in preparation for a bonded amalgam foundation.

unless it contributes to isolation. If the restorative mate- Caries

rial contributes to isolation, such as the mesial portion of
a mesial occlusal (MO) amalgam, it should be thinned
to keep it well away from hand and rotary instruments
while the case is treated. After endodontic treatment the
clinician removes the material and places a core.
Although some clinicians advocate removal of all decay be-
fore the initiation of endodontic treatment, two reasons ex-
ist to leave decay in place during instrumentation. Carious
but relatively firm tooth structure may aid in clamp place-
ment and retention and enhance isolation (Figure - 2-55).
42 Color Atlas o f Endodontics

FIGURE 2-56 A, Penetrating perpendicular to the occlusal surface of this mesially inclined
mandibular second molar bridge abutment will preclude locating the distal canals and could even
l ead to perforation through the mesial. B, Correct angulation relative to the root structure dramati-
cally skews the access to the mesial when viewed from the occlusal. This allows easier location and
instrumentation of the canals. C, The angle of entry is quite mesial. D, The explorer shows the angle
of entry into the prepared MB canal. E, The postoperative radiograph.
 Cbapter Two
Clearly soft, leathery decay should be removed, especially
if it might be abraded or dislodged into the canal. Removal
of all caries also aids the clinician in assessing restorability.
Inclined Teeth
Careful inspection of the preoperative radiograph usually
indicates an abnormal inclination in the mesiodistal di-
mension. Mesial inclination is a common finding in molar
teeth but can occur in any tooth, especially if an edentulous
area is located mesial to the tooth under treatment. Incli-
nations in the buccolingual plane are considerable less
common and can be detected by observing the curve of the
arch, the occlusal relationships, and the bony eminences
over the roots. Teeth that are routinely inclined include the
mandibular incisors, which are usually tilted to the labial,
and the mandibular second molars, which are usually tilted
to the mesial. The location and occasionally the shape of
the endodontic access may need to be modified to take
these inclinations into account (Figure 2-56).
Rotated and Malpositioned Teeth
As with inclined teeth, rotated and malposed teeth may
require modification to the endodontic access in light of
the ultimate goal of straight-line access to the canal
spaces. In anterior teeth a buccal access often facilitates
treatment and provides the clinician with better visualiza-
tion for locating the lingual canal in mandibular incisors. 13
Crowned Teeth
In their efforts to preserve tooth structure, avoid pulpal
exposure, and be "conservative," clinicians typically
under-prepare teeth receiving crowns. In most cases this
does not present a problem, but in more extreme cases of
under-reduction and in cases where the restored crown
has been shifted relative to the root structure these shifts
must be identified and incorporated into the endodontic
access. Access through existing crowns may also affect
retention by removing the retentive foundation and may
influence esthetics if porcelain fracture occurs. Teeth
with crowns require careful preclinical assessment and
often the use of unique treatment procedures (Figures
2-57 and 2-58).
Calcified and Difficult-To-Locate Canals
Without magnification and illumination, locating canals
can be among the most difficult, stressful, and error-
prone procedural aspects of endodontics and perhaps of
dentistry as a whole. The clinician should carefully and
realistically gauge the difficulty in locating canals, the
likelihood of a procedural mishap, and the relative im-
portance of the tooth in question (Figure 2-59).
Retreatment
Because most endodontically treated teeth have crowns,
retreatment usually occurs through the crown. With use
of the microscope, the clinician does not usually need to
Endodontic Access 43
remove a well-fitting, serviceable crown even when posts
are to be removed. Nevertheless, the presence of crowns
can and does complicate access (see previous section)
and therefore dictates changes in access outline form, es-
pecially in retreatment cases.
Access for retreatment should be spacious. The ulti-
mate goal must be kept in mind-if the endodontic com-
ponent cannot be managed, the tooth may be lost. The
clinician does better to risk destroying the crown than fail
to achieve the endodontic objective because of too small
an access.
Modifications for NiTi Rotary Instruments
Although rotary NiTi instruments do have markedly in-
creased flexibility, the clinician must be attentive in achiev-
ing straight-line access. Initially, this may seem counterin-
tuitive. However, the forces placed on these instruments as
they rotate around curvatures (especially cervical curva-
tures) are large. Changes in access design can greatly re-
duce stress on these instruments and decrease breakage.
Practitioners are often concerned with the difficulty
or impossibility of placing rotary NiTi instruments into
the access opening of posterior teeth-typically maxil-
lary second molars. As NiTi instruments become the in-
struments of choice in difficult cases, the difficulty in suc-
cessfully placing and using these instruments can be
traced to inadequate access. Clinicians should therefore
keep in mind that even in the specialty practice, only in
very rare cases can the access form not be modified to
facilitate rotary instruments (Figures 2-60 through 2-62).
Limited Opening
In patients with limited opening, clinicians may be
tempted to skimp on the access because fitting the head of
the handpiece into the interocclusal space is so difficult.
In these cases the clinician needs to redouble the effort to
gain adequate access. Limited opening coupled with poor
endodontic access is a setup for a difficult, frustrating,
less than satisfying case. Typically, in patients with limited
opening, the endodontic access should actually be larger
and more mesial to facilitate instrument placement. The
clinician should be acutely aware of the location and an-
gulation of the bur head because perforations and missed
canals are considerably more likely in these cases.
Author's Statement on Manipulation
o f Digital Images
The radiographs and images used in this chapter are al-
most all digital in origin. The radiographs are from Tro-
phy RVG and RVGui, with a few scanned radiographs
(the suboptimal ones). Color images have been taken
with a variety of technologies:
• Hitachi 3CCD microscope-mounted video camera
connected to a Trophy video capture board
44 Color Atlas of Endodontics

FIGURE 2-57 A, This mandibular canine was restored with a three-quarter crown to provide a rest
for a removable partial denture. After restoration the pulp became necrotic. Access opening through
the existing restoration may compromise retention and the rest configuration. B, A preoperative ra-
diograph reveals two separate roots. C, Access from the buccal approach enhances access to the lin-
gual canal and preserves the integrity of the existing restoration.
 Chapter Two Endodontic Access 45

FIGURE 2-58 A, This mandibular premolar was positioned distally before fabrication of a fixed par-
tial denture. As a result the contact was overextended to the mesial by the laboratory to close the
contact. In this occlusal view the access is distally placed relative to the occlusal surface. B, This fi-
nal radiograph with a combination amalgam/composite repair reveals that even though the access
was quite distal, it was still slightly mesial of true straight-line access.

FIGURE 2-59 A, The preoperative view of this maxillary first molar is deceptive. The relatively large
pulp chamber suggests easy-to-locate, patent canals. Note, however, the bulge into the pulp cham-
ber from the mesial. B, The classic mesial bulge. A stick can be felt along this line, but the MB 2
canal cannot be negotiated. Note that the mesial amalgam has been retained for isolation but
thinned to about 1 mm so as to not impede instrument placement. C, The telltale white dot of the
MB 2 orifice can be seen after use of the Mueller bur mesially and very slightly apically. D, A #10 file
can be seen to be somewhat sprung toward the distal, conforming the angle of entry.
46 Color Atlas o f Endodontics

FIGURE 2-60 The most common modification, useful even when rotary NiTi instruments are not
used, is to create a notch in the access that enhances visibility and straight-line access to the MB 2
canal. In most cases, creating this notch also provides a cleaner path of insertion for the DB canal.

FIGURE 2-61 The amalgam buildup under the crown on this
maxillary first molar exhibiting five canals encroached on access
to the MB2 canal. The area was fluted aggressively to eliminate the
possibility of the rotary NiTi instruments abrading the amalgam
during instrumentation and consequently creating amalgam scraps
and prematurely dulling the instruments. Note the dentin apical to
the amalgam.
FIGURE 2-62 I n this patient with limited opening, the entire ac-
cess outline was shifted to the mesial. The arrows represent the
views to the canals perpendicular to the occlusal surface and from
the mesial, as the clinician would see when clinically treating the
tooth. Note that the arrows are the same length, but the angled ar-
row requires less interocclusal space.
 Chapter Two Endodontic Access
• Sony DCR-PC 100 DV microscope-mounted cam-
era using the MemoryStick and imported to the
Trophy software
• Sony DCR-PC 100 DV microscope-mounted cam-
era using the S-Video output connected to a Tro-
phy video capture board
• Nikon Coolpix 950 microscope-mounted camera
using compact flash card and imported to the Tro-
phy software
• DMD Telicam Elite connected to a Trophy video
capture board
Images have been globally adjusted and spot adjusted
for brightness, contrast, and color balance. Images have
also been rotated, flipped, and cropped and converted
from the RGB colorspace used in CRTs to the CMYK
palette used in printing. These adjustments were made
to highlight the relevant anatomic features; correct for
the differences among cameras, light sources, and cap-
ture mechanisms; and overcome the limitations of tech-
nology when working down in deep, dark holes.
References
1. Walton R: Access preparation and length determination. In Walton
RE, Torabinejad M, editors: Principles and practice of endodon-
tics, Philadelphia, 2002, WB Saunders.
2. Green D: Double canals in single roots, J Oral Surg 35:689, 1973.
3. American Association of Endodontists: Endodontic case difficulty
assessment form, Chicago, American Association of Endodontists.
47
4. Stropko JJ: Canal morphology of maxillary molars: clinical obser-
vations of canal configurations, J Endodon 25(6):446, 1999.
5. Vertucci FJ: Root canal anatomy of human permanent teeth, Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 58:589, 1984.
6. Kasahara E et al: Root canal system of the maxillary central in-
cisor, J Endodon 16(4):158, 1990.
7. Burns RC, Herbranson EJ: Tooth morphology and cavity prepa-
ration. In Cohen S, Burns RC, editors: Pathways o f the pulp, ed 8,
St Louis, 2002, Mosby.
8. Carns EJ, Skidmore AE: Configuration and deviation of root
canals of maxillary first premolars, J Oral Surg 36:880, 1973.
9. Kulild JC, Peters DD: Incidence and configuration of canal sys-
tems in the mesiobuccal root of maxillary first and second molars,
J Endodon 16(7):311, 1990.
10. Mauger MJ et al: Ideal endodontic access in mandibular incisors,
J Endodon 25(3):206, 1999.
11. Benjamin KA, Dowson J: Incidence of two canals in human
mandibular incisor teeth, J Oral Surg 38:122, 1974.
12. Clements RE, Gilboe DB: Labial endodontic access opening for
mandibular incisors: endodontic and restorative considerations,
J Can Dent Assoc 57:587, 1991.
13. Baisden MK, Kulild JC, Weller RN: Root canal configuration of
the mandibular first premolar, J Endodon 18(10):505, 1992.
14. Hartwell G, Bellizzi R: Clinical investigation of in vivo endodon-
tically treated mandibular and maxillary molars, J Endodon
8(12):555, 1982.
15. Melton DC, Krell KV, Fuller MW: Anatomical and histological
features of C-shaped canals in mandibular second molars, J En-
dodon 17(8):384, 1991.
16. Weine FS: The C-shaped mandibular second molar: incidence and
other considerations. Members of the Arizona Endodontic Asso-
ciation, J Endodon 24(5):372, 1998.
TEB SINA CHEHR
(4070932 - 6418770)
50 Color Atlas o f Endodontics

FIGURE 3-1 Sure-Stop silicone endodontic stop dispenser. FIGURE 3-2 Endo-M-Bloc and File-mate stop setting and mea-
(Courtesy Dentsply Maillefer,Tulsa, OK.) suring devices. (Courtesy Dentsply Maillefer,Tulsa, OK.)

FIGURE 3-3 Chronological cementum deposition with subsequent deviation of the apical foramen.
(Redrawn from KuttlerY: Microscopic investigation of root apexes, JAm DentAssoc 50:544, 1955.)

APICAL REFERENCE POINT
Where should endodontic treatment terminate? In 1916
the theory was advanced that pulp tissue extends
through the apical foramen.11 Later, Grove contradicted
this and stated that the tissue in the foramen is peri-
odontal tissue, not pulp tissue, and is important for ce-
mentum formation via periodontal ligament cells after
pulp tissue remova1. 12 Grove later discussed the impor-
tance of always filling the root canal to the dentinoce-
mental junction (DCJ), which is "a definable point in all
cases." 13,14 This was based on a few histologic sections
taken from extracted immature teeth.
Coolidge also evaluated several histologic sections
of root ends and described the DCJ as an imaginary
line. He stated that the removal of pulp tissue near the
apical foramen is required for success, not pulp removal
at the DCJ or any other definable point." Grove was
also challenged by several other authors who reported
that the DCJ is rarely a definable point in teeth. After
examining more precise histologic data, they found that
not only is the DCJ rarely located near apical constric-
tion, but also that it occasionally is found on the exter-
nal root surface because of root resorption and ana-
tomic variation. 16,17
The first extensive investigation of root apex
anatomy was performed by Kuttler in 1955. 18 He evalu-
ated 268 teeth (primarily from cadavers) from which
402 root ends were split through the apical foramen and
 Chapter Three
FIGURE 3-4 Radiograph (A) and histologic section (B) of ideal
apical constriction on tooth #7.
examined. He reported several findings, including devia-
tion of the center of the foramen further from the apical
vertex with age and subsequent cementum deposition
( Figure 3-3). The minor diameter was usually found in
dentin. Kuttler concluded that the root canal should be
filled as far as 0.5 mm from the foramen because the av-
erage distance from the minor diameter to the foramen is
roughly 0.6 mm. Only 40% to 47% of apices had two
DCJs at the same level on the sections.
Burch confirmed Kuttler's results by finding the av-
erage deviation of the apical foramen from the anatomic
apex to be 0.59 mm in 877 teeth. He found that 40% of
these deviated in a buccal or lingual direction, making
Length Determination 51
FIGURE 3-5 Radiograph (A) and histologic section (B) of tooth
#29 with a slight apical constriction.
radiographic detection difficult. 19 Others have reported
average distances as large as 0.8 mm, 0.99 mm, 0.9 mm,
and 0.86 mm.20-23 Different tooth types have variable
anatomic configurations. The average distance between
the major foramen and the apex of anterior teeth has
been reported to be 0.26 mm, with 31 % opening directly
at the apex. For molars the average distance is 0.44 mm,
with 39% opening directly at the apex .24,25
The variability in apical canal anatomy makes work-
ing length determination extremely challenging. Canal
variations range from an ideal apical constriction (Fig-
ure 3-4), to slight apical constriction (Figure 3-5), to no
constriction at all (Figure 3-6). Frequently canals can
52 Color Atlas o f Endodontics

A B

FIGURE 3-6 Radiograph (A) and histologic section (B) of palatal root of tooth #15 with no api-
cal constriction.

A B

FIGURE 3-7 Radiograph (A) and histologic section (B) of mesial root of tooth #19 with apical
foramen well short of radiographic apex.

terminate several millimeters from the radiographic apex 3. Several constrictions

( Figures 3-7 and 3-8). This variability in apical canal
anatomy has been reported by Dummer, who examined
270 extracted teeth and categorized the apical anatomy
into five types of constrictions 26 ( Figure 3-9):
1. Typical single constriction
2. Tapering constriction with the narrowest portion
near the actual apex
4. Constriction followed by a narrow, parallel canal
5. Complete blockage of the apical canal by sec-
ondary dentin
Besides causing cementum deposition, resorptive
processes can also affect the relationships of the apical
anatomy and decisions regarding endodontic treatment
termination (Figures 3-10 and 3-11). Malueg examined
 Chapter Three Length Determination 53

A B

FIGURE 3-8 Radiograph (A) and histologic section (B) of mesial root of tooth #19 with apical
foramen well short of radiographic apex.

FIGURE 3-9 Dummer's classifications of apical canal anatomy. FIGURE 3-10 Radiograph (A) and histologic section (B) of
(Redrawn from Dummer PMH, McGinn JH, Rees DG: The position mesial root of tooth #31 with inflammatory root resorption.
and topography of the apical canal constriction and apical fora-
men, Int Endod J 17:192, 1984.)
54 Color Atlas o f Endodontics
A B
FIGURE 3-11 Radiograph (A) and histologic section (B) of distal root of tooth #30 with inflam-
matory root resorption.
49 root ends in 40 teeth with scanning electron mi-
croscopy and described the amount of apical resorption
occurring with preextraction pulpal and periapical diag-
nosis. 27 Out of 25 roots with necrotic pulps, 18 demon-
strated funneling (root resorption extending into the in-
ternal surface of the foramen), a number significantly
higher than that observed in vital pulps. Therefore "the
status of the pulp and periapical tissues should be con-
sidered when determining the length for preparation or
obturation." 27 Traumatic tooth injury also can cause
root resorption. Approximately 20% to 40% of the root
structure must be demineralized before buccal or lingual
root resorption can be detected radiographically.28 Some
researchers suggest calculating the working length 1 mm
short of the radiographic apex with normal apical
anatomy, 1.5 mm short with bone but no root resorp-
tion, and 2 mm short with bone and root resorption. 29
METHODS OF DETERMINING
WORKING LENGTH
Methods for determining working length include using
average root lengths from anatomic studies, preopera-
tive radiographs, tactile detection, or the "eye twitch"
response. Other common methods include bleeding on a
paper point and using working length radiographs made
with a variety of different film types or digital sensors,
electronic apex locators, or any combination of the
above.
Ideally, the clinician should measure working length
after attaining straight line access to the apical third of the
root canal system. The length may change slightly after
working length determination because of the elimination
of the coronal deflection of the working length . 30, 8 This is
especially true in the mesial canals of molars, where much
of the total curvature of the canal is eliminated after the
cervical bulge is removed. Moreover, attaining straight
line access and preflaring the canal space greatly improves
tactile detection of the apical constriction.31
Radiography
Since Wilhelm Roentgen's discovery of the x-ray in 1895,
continued efforts have been made to reduce the amount
of ionizing radiation exposure to the patient while im-
proving or maintaining image quality. Otto Walkhoff's
production of the first dental radiograph required 25
minutes of exposure time. 32 Current methods to reduce
radiation exposure include using the paralleling tech-
nique instead of the bisecting angle technique and em-
ploying rectangular long cone techniques, faster radio-
graphic film, digital radiographic techniques, and
electronic apex locators to assist in endodontic treat-
ment." Rectangular collimation can decrease the radia-
tion exposure by 40% compared with a 6 cm round
beam, E-speed film can decrease exposure by 40% over
D-speed film, and constant potential x-ray units can de-
crease exposure by 40% compared with conventional al-
ternating current units. 34
As steps are made to reduce patient radiation expo-
sure, the quality of working length determination must
not be sacrificed . 35 When radiographs are used to deter
mine working length, the quality of the image is impor-
tant for accurate interpretation. Paralleling techniques
have been demonstrated as superior to bisecting angle
radiographic techniques in interpretation of length de-
termination and reproduction of apical anatomy. 16-38 A s
 Chapter Three
the angle increases away from parallel, the quality of the
i mage decreases.37 This occurs because as the angle is in-
creased, the tissue that the x-rays must pass through in-
cludes a greater percentage of bone mass and root
anatomy becomes less discernible. To limit some of these
problems, the "modified paralleling" technique has been
suggested by Walton; in this technique the central beam
is oriented perpendicular to the radiographic film, but
not to the tooth. 29
Several choices are available regarding radiographic
film and processing. No significant difference has been
demonstrated in the diagnostic quality of E-Plus radio
graphic film compared with D-speed film. 39-43 For this
reason, E-Plus film should be used to reduce radiation
exposure to the patient. Rapid processing chemicals
are also used in endodontics to expedite the develop-
ment of film for treatment radiographs. When tested,
these rapid techniques provided similar diagnostic
quality to normally processed radiographs for working
length determination. 42
Parallel working length radiographs can be difficult
to attain because of misorientation, shallow palatal
vault, and tori. Products such as the "Endo-Ray II" (Fig-
ure 3-12) (Dentsply Rinn, Elgin, IL) may help produce
more predictable results. This alignment device assists in
making a parallel working length radiograph without re-
moving the rubber dam clamp or files from the tooth.
Dental students using hemostats produced acceptable ra-
diographs in 66% of maxillary and 75% of mandibular
teeth on patients undergoing endodontic treatment.
When the Endo-Ray II was used, acceptable radiographs
were made in 87% of maxillary and 85% of mandibular
teeth .44
Because increased vertical angulation is often neces-
sary when making maxillary radiographs, zygomatic
arch interference becomes a significant problem in inter-
preting apical anatomy and determining working length.
Approximately 42% of maxillary second molars and
20% of first molars exhibit this interference.45
An understanding of the buccal object rule (BOR) is
essential to endodontic treatment. The main concept of
the rule is that as the vertical or horizontal angulation
of the x-ray source or tube head changes, the object buc-
cal or closest to the tube head moves to the opposite side
of the radiograph compared with the lingual object. For
example, if a working length radiograph is of a maxil-
lary first premolar with no horizontal angulation (buccal
and lingual roots are superimposed) and too little verti-
cal angulation (apex is not captured on radiograph), a
new working length radiograph is necessary. To separate
the buccal and lingual roots to visualize the individual
working length file's relationship to the apical root struc-
ture, the clinician should place the tube head from a 20
degree mesial angulation. This captures the buccal root
on the opposite or distal side of the radiograph and the
lingual root on the mesial side of the radiograph. To cap-
Length Determination 55
FIGURE 3-12 Endo-Ray II film holder. (Courtesy Dentsply Rinn,
Elgin, IL.)
ture the entire apical portion of the roots, the vertical an-
gulation of the tube head should be increased from a
positive, or superior, position. This is demonstrated on
the radiograph as the buccal root appearing more infe-
rior, or coronal, to the lingual root (the opposite direc-
tion of the tube head angulation) and the lingual root
appearing toward the superior, or top, of the film. This
rule can also be applied to locating root resorptive
processes in relation to a tooth, identifying anatomic
landmarks and pathosis, locating a canal in relation to a
radiopaque marker such as a bur in the access, or locat-
ing the position of additional roots . 46 Additionally, to in-
crease visualization of apical anatomy, this rule can be
used to "move" anatomic landmarks such as the zygo-
matic process or impacted teeth .47 It also helps identify
the angle at which a particular radiograph was made
even if the information was not recorded. For example,
the palatal root of a maxillary molar curves to the distal
side and is located toward the distobuccal root rather
than between the two buccal roots when the angle of the
radiograph is from the mesial side. Extensive informa-
tion on the BOR has been reported by Richards. 48 Other
names for the BOR include the SLOB (Same Lingual,
Opposite Buccal) rule, the BOMM (Buccal Object
Moves Most) rule, Clark's rule, and Walton's projec-
tion . 49 Walton suggests an easy method to simplify this
concept. Place two or three fingers in front of your eyes
to represent the roots of a particular tooth. As you move
your head to the "mesial," or for demonstration pur-
poses to the right, while keeping your fingers in the same
position, you will notice that the "buccal" object, or the
finger closest to your face, will move to the "distal" or
left. This is exactly the way a structure would be pro-
j ected on the radiographic film and can be applied to ver-
tical angulation in a similar fashion . 2 9
Although the individual canals can usually be deci-
phered by applying the BOR and knowing the angle at
56 Color Atlas of Endodontics
FIGURE 3-13 Film placement for maxillary working length ra-
diographs. (Redrawn from Walton RW,Torabinejad M: Principles and
practice of endodontics, ed 3, Philadelphia, 2002, WB Saunders.)
which the radiograph was made, misinterpretation is still
possible. This can be reduced by using different file types
(e.g., Hedstrom, K-file) or different file sizes (e.g., 15, 25,
35) in adjacent canals.35
Preoperative periapical radiographs have been used
to calculate the working length for endodontic treat-
ment. 36 Because a magnification of about 5.4% is em
ployed in the paralleling technique, 1 to 2 mm must be
subtracted from the measurement on the preoperative
radiographs° Pantographic radiographs have not been
advocated for calculating the estimated working length
because of the gross magnification of 13% to 28% that
is employed.51 "Radiographic incrementation" is the
process of using a millimeter grid stamped on the film
or a copper grid to measure working length. Using these
measurements alone can produce unfavorable re-
sults.52,36 Rather than using this method alone to mea-
sure working length, which was commonly done in the
early years of endodontic treatment, this measurement
can be used as an "estimated working length" that can
then be confirmed by placing an endodontic instrument
into the canal and taking a second radiograph. The
"corrected working length" can then be calculated by
adding or subtracting the distance between the instru-
ment tip and the desired apical termination of the root.
This technique was first introduced by John Ingle.5 3
When measuring the distance from the file tip to the ad-
j usted stop with a metric ruler, it is important to
straighten any curvatures present in the working length
file to prevent misinterpretation.
When rubber dams are in place, working length ra-
diographs can be challenging. The rubber dam frame
should be left in place to maintain isolation, but one cor-
ner of the dam can be released to facilitate placement of
the film. For this reason, plastic rubber dam frames
should be used in endodontic treatment.
FIGURE 3-14 Film placement for mandibular working length ra-
diographs. (Redrawn from Walton RW,Torabinejad M: Principles and
practice of endodontics, ed 3, Philadelphia, 2002, WB Saunders.)
Angled working length radiographs help separate
overlapping canals, especially in mandibular teeth and
maxillary premolars. Walton outlined the ideal orienta
tion and angles for working length radiographs in max-
i llary and mandibular teeth (Figures 3-13 through 3-15).
Maxillary anterior teeth only contain single canals, and
maxillary molars require straight-on radiographs. The
palatal canal is centered between the mesiobuccal and
distobuccal roots in maxillary molars. When a second
mesiobuccal canal (MB 2 ) is suspected, a mesial radio-
graph is often required to identify it. However, as the
horizontal angulation increases, the clarity of the radic-
ular anatomy decreases. A 20 degree mesial shift is suf-
ficient to separate the canals while limiting distortion.
When making maxillary radiographs, the operator
places the film parallel to the tooth and perpendicular to
the central ray and as far apical as possible. Generally
the radiograph is placed at the junction of the hard and
soft palate for maxillary anterior teeth and on the oppo-
site side of the palate for maxillary posterior teeth (see
Figure 3-13). Mandibular radiography also has some
challenges. The radiographic film is placed as close to the
tooth and as parallel to the tooth as possible to limit dis-
tortion. Generally this can be achieved by placing the
film deep in the vestibule. If the patient closes the mouth
slightly, the film generally can be placed more apically as
the mylohyoid muscle relaxes .29
New Technology
Advances in electronics and computers are generating
many treatment adjuncts in endodontics and specifically
in working length determination. Careful analysis and
use of these devices is crucial to provide improved patient
care now and in the future. Bender stated on his ninetieth
birthday celebration, "The clinical practice of yesterday's
endodontics becomes the heresy of today and today's en-
 Chapter Three
FIGURE 3-15 Orientation of film on opposite side of palate when
making maxillary posterior working length radiograph. (Redrawn
from Walton RW, Torabinejad M: Principles and practice of en-
dodontics, ed 3, Philadelphia, 2002, WB Saunders.)
FIGURE 3-17 Gendex GX-S CCD intraoral sensor. (Courtesy Dentsply Gendex, Des Plaines, IL.)
dodontic practice becomes the heresy of tomorrow. So
don't be so rigid in your techniques or beliefs. ''29a
DIGITAL RADIOGRAPHY. For the past 100 years, film-
based radiography has been the dominant imaging tech-
nique used in dentistry. Although commonplace in med-
icine for many years, charged coupled device (CCD)
sensor-based digital radiography was first introduced to
dentistry by Trophy (Trophy Radiologie, Vincennes,
France) with the RadioVisioGraphy (RVG) system in
1987. Since that time, other digital systems have entered
the market. These include Sens-A-Ray (Regain Medical
Length Determination 57
FIGURE 3-16 Gendex GX-S CCD-based digital radiography sys-
tem. (Courtesy Dentsply Gendex, Des Plaines, IL.)
Systems AB, Sundsvall, Sweden), Gendex GX-S
( Dentsply Gendex, Des Plaines, IL) (Figure 3-16), Flash
Dent (Villa Sistem Medicale srd, Buccinasco, Italy),
Schick CDR (Schick Technologies, New York, NY), and
several others. Modifications of the original systems
include larger sensor sizes comparable to size #2 film,
thinner and more manageable intraoral sensors (Figure
3-17), and integration with intraoral cameras and pa-
tient management database software (Figure 3-18).
Since the introduction of dental digital radiography by
Trophy in 1987, its use in endodontics has increased be-
cause of the ability to produce instantaneous images dur-
58 Color Atlas of Endodontics
FIGURE 3-18 Gendex DenOptix software demonstrating working
l ength estimation. (Courtesy Dentsply Gendex, Des Plaines, IL.)
ing working length determination. This technology uses a
CCD chip inside an intraoral sensor that produces an im-
mediate digital image on the monitor after exposure to
about 50% or less of the radiation exposure required by
E-speed film. This image can be stored, enhanced, or
placed in the patient record. If the apical anatomy cannot
be visualized, another image can be made by readjusting
the position indicating device (PID) or the intraoral sensor.
CCD-based digital radiography systems such as the Tro-
phy RVG, Seamens Sidexis, Regam Sens-A-Ray, and Visu-
alix Vixa all have been demonstrated to be similar in work-
ing length determination to D- and E-speed film. 54-62
Although first described in the medical literature in
1983 by Sonoda et al, storage phosphor-based digital ra-
diography was introduced by Fuji (Fuji Inc., Tokyo,
Japan) in 1981. More recently, Soredex (Orion Corp.
Ltd., Helsinki, Finland) has introduced an intraoral com-
puted radiography system called the Digora. This system
also uses the Fuji sensor and was first described in 1994
by Kashima. 63 It uses a flat imaging plate containing phos-
phor granules that fluoresce when exposed to ionizing ra-
diation. About 50% of the latent energy remains stored in
the imaging plate, similar to an intensifying screen, until
the image is read by the scanner. After exposure, the
imaging plate is disinfected, removed from its sealed plas-
tic cover, and placed into a laser reader that produces a
digital image within 30 seconds. The image can then be
viewed on the monitor, enhanced, or stored in the patient
record. These systems are similar in cost to intraoral
CCD-based sensor systems. Although the image is not im-
mediately viewed on the monitor after exposure, its ben-
efits include a sensor that is similar in thickness and flex-
ibility to a #2 size conventional film (Figure 3-19).
The largest Digora sensor is similar in size and thick-
ness to a #2 dental film. The sensor dimension is 35 X
45 X 1.6 mm. The imaging area is 30 X 40 mm and 416
X 560 pixels. Each pixel is 70 X 70 um. The resolution
has been reported as more than six line pairs per mil-
limeter. The uncompressed image file size is 234 kilo-
bytes. 64
Working length determination using storage phos-
phor radiography has also been demonstrated to be sim-
ilar to that using D- and E-Plus speed film. 62,65,66 Brettle
demonstrated that Digora images of similar quality to
Kodak Ektaspeed (E-speed) film were acquired with ex-
posure times 80% less than those of film. 67
Gendex has introduced a storage phosphor system
called DenOptix (Dentsply Gendex, DesPlaines, IL)
( Figure 3-20). This new technology uses the same pro
cessing equipment to read numerous sizes of storage
phosphor-based film (Figure 3-21).
Other emerging digital technologies using the CCD-
based sensor are being explored. One example is
Panoramic Corporation's latest innovation called RTLX
( Panoramic Corporation, Fort Wayne, IN). This is a pre-
li minary product that boasts full-motion digital radiog-
raphy with minimal radiation dosage. This system allows
radiographic imaging during treatment procedures sim-
ilar to those used in interventional radiography. Al-
though the technology is exciting, protective barrier
techniques must be further explored because of the con-
stant radiation exposure to patients and health care
providers from the fluoroscope. A similar technology
was reported in the literature in 1983; it was called the
DXT 100. 68
ELECTRONIC APEX LOCATORS. Radiographs are often
misinterpreted because of the difficulty of discerning
radicular anatomy and pathosis from normal struc-
tures.69,70 Electronic apex locators are used for working
length determination as an adjunct to radiography. They
should be used when the apical portion of the canal sys-
tem is obstructed by impacted teeth, tori, the malar
process, the zygomatic arch, excessive bone density,
overlapping roots, shallow palatal vaults, or even nor-
mal medullary and cortical bone patterns. In these cases
they can provide information that radiography cannot.
They may also be used in the treatment of pregnant pa-
tients to reduce radiation exposure, in children who may
not tolerate taking radiographs, and in disabled or heav-
ily sedated patients. If a patient does not tolerate radio-
graph placement because of the gag reflex, electronic
apex locators can be a valuable tool. Sewerin evaluated
full mouth radiographic series taken on 478 patients and
found that 13% exhibited a significant gag reflex and
1.3% were unable to tolerate completion of the radio-
graphic examination . 71 Patients with disabilities or de-
bilitating disorders such as Parkinson's disease may not
be able to hold the film in place. Children also may have
difficulty with this task. Because as many as 40% of de-
viations of canal foramen from the apical center are in
 Chapter Three Length Determination 59

FIGURE 3-19 Endodontic case treated with Soredex Digora digital radiography system.

FIGURE 3-20 Gendex Den Optix storage phosphor system. (Cour- FIGURE 3-21 Gendex DenOptix software interface. (Courtesy
tesy Dentsply Gendex, Des Plaines, IL.) Dentsply Gendex, Des Plaines, IL.)
60 Color Atlas of Endodontics
the buccal or lingual plane and apical canal curvature is
in the buccal or lingual plane, electronic apex locators
can provide good information where unknown curves
may otherwise go undetected with radiographic film.72,73
Electronic devices such as electronic apex locators
should not be used on patients who have cardiac pace-
makers. The "demand" type pacemakers (the most com-
monly used today) that stimulate the heart only when
necessary are most affected by electronic equipment . 74,75
In 1942, Suzuki found in experiments on dogs that
the electrical resistance between an instrument in the
canal and the mucous membrane is a consistent value.
These principles were not examined further until Sunada
performed a series of experiments on patients and found
that the electrical resistance in the canal at the apex, mu-
cosa, and periodontal ligament was 39 to 41 mA with
very little variance when measured with an ohmmeter.7 6
He then demonstrated that when a reading of 40 mA was
attained, the apex was consistently located. Huang found
the same constant resistance in vitro.77 Therefore he
claims it is a physical and not a biologic phenomenon.
Inuoe developed a sonic readout system using a transistor
equalizer-amplifier that converts the feedback to sound.
One of the most widely used apex locators in the
1970s and 1980s was the Sono-Explorer (Union Broach,
New York, NY). An article was published reporting the
accuracy of the Sono-Explorer to be only 48% com-
pared with a digital-tactile sense accuracy of 64% . 7s A
flurry of letters was published in later issues of the jour-
nal o f the American Dental Association condemning this
FIGURE 3-22 J. Morita Root ZX electronic apex locator. (Cour-
tesy J. Morita Co., Kyoto, Japan.)
article by practitioners who felt they used their instru-
ments with a great deal of success. Since that time, more
sound clinical testing has been performed and apex lo-
cators continue to evolve and improve.
Because of the problems caused by the interaction of
electronic apex locators with moisture and endodontic
irrigants in the canals, devices were developed to operate
in moist conditions. The Endocator (Hygienic Corpora-
tion, Akron, OH) was the first to do this, using a Teflon-
coated probe instead of files for working length determi-
nation. This insulated the measuring device from canal
irrigants and tissue, but the instruments were not always
fine enough to pass through the apical constriction. Also,
the Teflon coating tended to break away from the probes
with time, altering the accuracy of the device.
Most recently, third-generation electronic apex loca-
tors have entered the market. They can operate in a wet
environment, even one containing sodium hypochlorite,
and appear to be much more accurate compared with
previous devices. They use two different frequencies and
average the change as the apex is reached to provide a
much smoother reading in different conditions. The first
of this generation was the Osada Endex, or Apit as it is
called outside the United States (Osada Electrical Co.,
Tokyo, Japan). This apex locator must be used in a moist
environment and is calibrated by being reset with the file
a few millimeters into the canal before a measurement is
taken of each canal. The apical terminus is reported with
a constant tone as well as a meter that reflects the posi-
tion in the canal. The J. Morita Root ZX (Figure 3-22)
FIGURE 3-23 Analytic Endo Analyzer electronic apex locator and
electronic pulp tester. (Courtesy Analytic Endodontics, Orange, CA.)
 Chapter Three
(J. Morita Co., Kyoto, Japan) can be used in either a wet
or dry environment, including blood, sodium hypochlo-
rite, and saline. It uses a tone as well as a digital readout.
The Root ZX has been demonstrated in the literature to
be the most accurate apex locator on the market. The
Analytic Apex Finder (Analytic Endodontics, Orange,
CA) uses three different frequencies with a digital read-
out, but no studies have been reported yet to demon-
strate its performance. Analytic also produces the Endo
Analyzer (Figure 3-23), which acts as an electronic apex
locator as well as an electric pulp tester.
The working length measured to clean, shape, and
obturate a canal space may not always be measured to
the apical constriction. In cases of root perforation, the
Length Determination 61
point of exit of the canal to the periodontal ligament
space is a crucial measurement. If the perforation occurs
on the buccal or lingual or furcal surface of the tooth, it
may be difficult to detect. Apex locators can be reliable
instruments to detect perforations and the length to the
area where the perforation exits the tooth structure . 79-82
An electronic apex locator can also be placed on a post
to confirm that the post is perforated or on a pin to de-
tect whether it has been placed into the pulp space. 83
When electronic apex locators are compared for ac-
curacy in the literature, scientific methods used include
simulated acrylic canals, animal, cadaver, and human
studies (Table 3-1). A defined acceptable range of accu-
racy among working length determinations is plus or
Continued
62 Color Atlas of Endodontics
minus 0.5 mm from the apical constriction. Researchers
averaged the accuracy of 12 studies assessing the Sono-
Explorer, a second-generation apex locator, and found
that 76% of the measurements fall within this range. 78,84-
94 A third-generation electronic apex locator, the Endex,
has been shown to be 86% accurate according to the av-
erage of five studies. 95-99 Researchers averaging the ac-
curacy of another third-generation apex locator, the
Root ZX, in seven studies found it to be 94% accu-
rate. 100-105 The most clinically relevant data can be gath-
ered from blinded studies where working length is de-
termined with any test method, cementation of the file
in position, extraction of the tooth, and direct measure-
ment of the file tip from the apical constriction. When
only these types of studies are used to compare apex lo-
cators, the Sono-Explorer is found to be 83% accurate
( five studies), the Endex is 79% accurate (two studies),
and the Root ZX is 92% accurate (five studies). The per-
cent accuracy of these three commonly used electronic
apex locators is summarized in Table 3-2.
Recently, apex locators have been married to other
endodontic instruments. The Tri Auto ZX (J. Morita
Co., Kyoto, Japan) (Figure 3-24) is a rechargeable elec-
tric handpiece that rotates nickel titanium files at 240 to
280 rpm and has the electronic components of an apex
locator built in. When the file reaches the preset working
length (e.g., 1.0 or 1.5 mm short of the apical constric-
tion as read by the electronic apex locator), the file au-
tomatically reverses direction and backs out of the canal.
This auto-reverse mechanism also begins when excessive
torque is sensed by the handpiece to avoid possible in-
strument separation.106 When tested on extracted teeth,
the canals were instrumented to 0.1 mm short of the
electronically measured length when set at 1.0 mm; how-
ever, the apical constriction was commonly overpre-
pared. 107 An ultrasonic device called the Solfy ZX (J.
Morita Co., Kyoto, Japan) has also been introduced. It
combines an ultrasonic handpiece with electronic apex
locator technology. This instrument also can be set to
stop vibrating when a preset length is detected by the
electronic apex locator. It has been demonstrated that
when the auto-stop function is set at 2, the chance of
over-enlarging the apical constriction is lessened com-
pared with a setting of 1. 108
When using electronic apex locators to determine
working length, the clinician should keep in mind that
metallic restorations may interfere with the reading of
the device if the working length file comes into contact
 Chapter Three
FIGURE 3-24
Kyoto, Japan.)
with the restoration or fluid that is in contact with the
restoration. This problem can be avoided by initially
drying the coronal canal space and chamber before mea-
surement or by using a silicone-containing material
within the canal spaces, such as Gly-Oxide (Marion Lab-
oratories, Inc., Kansas City, MO).
The most important thing to do when determining
working length is to use as many of the techniques as
possible during the course of treatment. First the clini-
cian should secure a stable coronal reference point(s).
The next step is to estimate working length from the his-
torical average lengths and the preoperative radiograph
and keep this estimate in mind throughout treatment. Fi-
nally, the clinician should use rational thought in com-
bining tactile sense, radiography, and electronic devices
to arrive at the desired apical terminus of the endodon-
tic preparation.
Length Determination 63
J. Morita Tri Auto ZX. (Courtesy J. Morita Co.,
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95. Felippe MCS, Soares IJ: In vitro evaluation of an audiometric de-
vice in locating the apical foramen in teeth, Endod Dent Trau-
matol 10:220, 1994.
96. Arora RK, Gulabivala K: An in vivo evaluation of the Endex and
RCM Mark II electronic apex locators in root canals with differ-
ent contents, Oral Surg Oral Med Oral Pathol Oral Radiol En-
dod 79:497, 1995.
97. Frank AL, Torabinejad M: An in vivo evaluation of Endex elec-
tronic apex locator, J Endod 19:177, 1993.
98. Lauper R, Lutz F, Barbakow F: An in vivo comparison of gradi-
ent and absolute impedance electronic apex locators, J Endod
22:260, 1996.
99. Ounsi HE Haddad G: In vitro evaluation of the reliability of the
Endex electronic apex locator, J Endod 24:120, 1998.
100. Czerw RJ et al: In vitro evaluation of the accuracy of several elec-
tronic apex locators, J Endod 21:572, 1995.
101. Dunlap CA et al: An in vivo evaluation of an electronic apex lo-
cator that uses the ratio method in vital and necrotic canals,
J Endod 24:48, 1998.
102. Katz A, Mass E, Kaufman AY: Electronic apex locator: a useful
tool for root canal treatment in the primary dentition, ASDC
J Dent Child 63:414, 1996.
103. Pagavino G, Pace R, Baccetti T. A SEM study of in vivo accuracy
of the Root ZX electronic apex locator, J Endod 24:438, 1998.
104. Shabahang S, Goon WW, Gluskin AH: An in vivo evaluation of
Root ZX electronic apex locator, J Endod 22:616, 1996.
105. Vajrabhaya L, Tepmongkol P: Accuracy of apex locator, Endod
Dent Traumatol 13:180, 1997.
106. Kobayashi C, Yoshioka T, Suda H: A new engine-driven canal
preparation system with electronic canal measuring capability,
J Endod 23:751, 1997.
107. Campbell D et al: Apical extent of rotary canal instrumentation
with an apex-locating handpiece in vitro, Oral Surg Oral Med
Oral Patbol Oral Radiol Endod 85:319, 1998.
108. Kobayashi C, Yoshioka T, Suda H: A new ultrasonic canal prepa-
ration system with electronic monitoring of file tip position, J En-
dod 22:489, 1996.
TEB SINA CHEHR
(4070932 - 6418770)
68 Color Atlas of Endodontics

FIGURE 4-1 Scanning electron microscopic view of an unpre- FIGURE 4-2 Scanning electron microscopic view of a prepared
pared type II canal in a mandibular incisor. type II canal in a mandibular incisor. Note the areas of debris and
uncleaned canal space.

A B

FIGURE 4-3 A, C-shaped morphology in this mandibular second molar complicates instrumen-
tation. B, Resin cast of a C-shaped canal from a mandibular second molar.

irrigant should be nontoxic, capable of dissolving both
vital and necrotic pulp tissue, kill bacteria, lubricate,
and remove the smear layer. 3-10 At least one study has
found that the smear layer seems to inhibit bacterial
growth." Presently, no single irrigant possesses all of
these traits.
The most common intracanal irrigant used is sodium
hypochlorite. Other irrigants that have been studied
alone or in combination with sodium hypochlorite in-
clude 3 % hydrogen peroxide, ethylenediaminetetraacetic
acid (EDTA), citric acid, and lactic acid. 10,12-20
Sodium hypochlorite has been shown to be an effec-
tive antimicrobial agent when placed in contact with
bacteria. 21-23 However, bacteria are never totally elimi
nated because a sufficient volume of irrigant does not
reach all aspects of the canal space or dentinal tubules.
To facilitate penetration of the canal system, the use
of 27- or 28-gauge irrigating needles with a Luer-Lok sy-
ringe is suggested. As the apical preparation approaches
a size 45 file, the ability of the solution to reach the api-
cal extent of the canal through a 27-gauge needle im-
proves. 24 One study comparing closed-tip needles with a
 Chapter Four Canal Preparation 69

side portal with other irrigation techniques found these

syringe tips were the most effective in removing dye from
plastic artificial canals . 25
Sonic and ultrasonically activated devices are capa-
ble of delivering larger volumes of irrigant in smaller
canals, but they require special equipment and instru-
ments. 26,27 Few of these current vibrating devices are ca-
pable of delivering sodium hypochlorite because of its
corrosive action on aluminum components.
Lubricating pastes are often employed in canal prepa-
ration with sodium hypochlorite. In addition to facilitat-
ing placement of the file, these pastes also entrap debris.
Dentin chips are held in suspension and are less likely to
be packed in the apical portion of the canal.

Instruments
Over the second half of the twentieth century, advances
i n endodontic instruments and techniques allowed mil-
lions of previously condemned teeth to be saved. The
early pioneers in endodontics recognized the significance
of complete debridement and disinfection of the canal
space in ensuring eventual endodontic success. However,
their initial selection of endodontic files and reamers
from various manufacturers was limited. In a coopera-
tive effort, both the American Dental Association (ADA)
Council on Dental Materials and the American Dental
Manufacturers worked together to develop instrument
standardization and ADA specification No. 28. 28
In the early 1970s, most accepted instrumentation
techniques emphasized hand debridement with minimal
use of handpiece-driven instruments except for orifice en-
largement. Specification No. 28 was developed for hand-
operated K-type files and reamers and was first published
in 1976. This specification established tip diameter, taper
(increase of diameter for each millimeter of length), tor-
sional limits, and other physical attributes for files. Speci-
fication No. 58 was developed for Hedstrom files and was
published in 1982. 29 Revised standards for specifications
No. 28 and No. 58 were published in 1989.-10
Presently, no approved standards are available for ro-
tary instruments, but the American National Standard/
ADA Council on Scientific Affairs has proposed Specifi-
cation No. 95 for root canal enlargers. 31 This document
is based largely on published reports from a Marquette
University group that examined the torsional, bending,
and metallurgical properties of all stainless steel engine-
and carbon steel engine-driven endodontic enlargers. 32-36
No recognized standards are available for nickel-
titanium instruments; however, the manufacturers
must meet the United States Food and Drug Adminis-
tration's (FDA's) Good Manufacturing Practice Regu-
lations before introducing a new device.
The following discussion of canal preparation tech-
niques assumes that all files or reamers are hand oper-
ated unless otherwise stated. Instrumentation techniques
that require specific instruments are identified at the time
of their discussion.
FIGURE 4-4 The standardized preparation technique resulted in
procedural errors when used in a curved canal. Dentin was re-
moved from the inner wall of the canal coronal to the curve and
from the outer wall of the canal apical to the curve.This resulted in
an "hourglass" preparation. In the apical portion the canal was
transported, or "zipped;' when larger, less flexible instruments were
used at the correct working length.
Canal Preparation Techniques
From a historical perspective, clinical techniques tend to
build on previously successful techniques. Therefore the
various canal preparation techniques will be introduced in
chronologic order, beginning with hand debridement tech-
niques using stainless steel instruments. A few assumptions
are made here to facilitate understanding of the differences
among the techniques. These assumptions may not apply
in actual clinical cases. The primary goal of all these tech-
niques is to shape the canals to the apical constriction of
the canal space, regardless of the radiographic appearance
of the actual tooth. The guidelines for shaping outlined by
Schilder are followed in this discussion . 2
Before initiating any treatment, the clinician should
evaluate each case and determine the degree of difficulty.
As the complexity increases, the ability to clean and
shape decreases, and the potential for procedural errors
increases. Procedural errors include loss of working
length, transportation of the apex (or zipping), apical
perforation, lateral stripping, and instrument breakage
( Figure 4-4). The following criteria are suggested for
evaluation of cases before treatment:
Root length-Longer roots are generally more diffi-
cult to treat.
Root width-Narrow, curved roots are at risk for
apical and lateral stripping perforations.
70 Color Atlas of Endodontics

Canal size-Small canals are more difficult to pre-

pare and may not exhibit any natural taper.
Canal curvature-Difficulty increases as curves
progress from gentle to sharp dilacerations.
Calcifications-Calcification makes location and ne-
gotiation more difficult.
Resorptions-Resorptions present potential problems
for negotiation, cleaning, shaping, and obturation.
Restorations-Restorations may change the orienta-
tion of the tooth in the dental arch, block canals,
and restrict vision.
Previous treatment-Teeth exhibiting previous root
canal treatment are more difficult to manage for a
variety of reasons. Normal anatomic landmarks
may have been removed, procedural errors may be
present, and debris in the root canal system may
be difficult to remove.

STANDARD TECHNIQUE. John Ingle was a member of
the first committee to propose standardization of en-
dodontic instruments and introduced the classic "stan-
dardized preparation." 17 Standardized files were used se-
quentially to produce a canal preparation that had the
same size and shape (taper) as the last standardized in-
strument used. The canal could then be obturated with a
filling material that was also the same size and shape. Es-
sentially, the canal was made to fit the filling material.
At this same time, obturation with silver points having
the same shape as the files was an accepted and popular
obturation technique.
The technique was easy to perform in straight canals
of mature teeth exhibiting natural taper but posed prob-
lems in small, curved canals. As the instruments got larger,
the ability to finesse the stiff instruments to different
lengths decreased because of the restoring force of the
metal. This often resulted in ledging, apical transportation,
and apical perforation, or "zipping" (see Figure 4-4). 38-40
STEP-BACK TECHNIQUE. The realization that curved
canals may require less aggressive instrumentation re-
sulted in the introduction of the step-back preparation
technique.41 Several comparative debridement studies
have been performed that demonstrate the superiority of
the step-back preparation over the standard technique. 4 2
The step-back technique emphasizes keeping the apical
preparation small, in its original position, and produc-
ing a gradual taper. The working length is established
and then the first file to bind is set as the master apical
file (MAF). Subsequent larger files are introduced at
1-mm or shorter increments (Figure 4-5). After each step
back, the canal is irrigated and the MAF replaced to the
established working length to remove any loosened de-
bris. The step-back "telescoped" preparation produces
a canal with greater taper compared with the standard
technique and results in more dentin removal and
cleaner canal walls. 43,44
FIGURE 4-5 A, To reduce procedural errors encountered with the
standardized preparation technique, the step-back technique was
developed. After the working length and MAF were established, suc-
cessive instruments were shortened by 1-mm increments and used
to develop a more tapered preparation. B, Canal bed enlargement
permits the development of a tapered preparation using a more
flexible process. After working length determination and establish-
ment of the MAF, successive instruments are introduced to the ini-
tial point of binding and then rotated one half turn. No attempt is
made to force the instrument to the working length or artificial pre-
determined length.
As an alternative to the step-back preparation,
Schilder advocated canal bed enlargement .2 After deter-
mining the length determination and establishing the
largest MAF, the clinician places the next larger instru-
ment into the canal to the point of initial contact and
rotates it one half turn. Force is not applied to the in-
strument in an apical direction and no effort is made to
advance the instrument to the working length. The
canal is then irrigated and the process repeated with in-
creasingly larger instruments (see Figure 4-5). The tech-
nique allows the body of the canal to be prepared with-
out the procedural errors inherent in the standardized
preparation technique. In addition, the technique per-
mits the natural morphology of the canal to influence
the preparation, in contrast to the more ridged incre-
mental step-back technique. After completion of the ta-
pering process, Schilder advocates the use of Gates Glid-
den drills in the canal orifice to remove coronal
obstructions.
Weine emphasized pre-curving files to minimize canal
alteration. However, pre-curving does not guarantee to-
tal canal symmetry and alterations occur despite the best
efforts of the clinician. 45-47
 Chapter Four Canal Preparation 71

FIGURE 4-6 Gates Glidden drills are used in the coronal portion
of the canal for orifice enlargement and straight line access. Before
using the Gates Glidden drills, the clinician should evaluate the
sizes of the canal and root as they relate to the diameter of the
instrument.
FIGURE 4-7 Straight line access is facilitated by removing over-
hanging ledges of dentin before using the Gates Glidden drills. This
can be accomplished by either slow- or high-speed instrumentation.

Later variations of the original step-back technique BOX 4-1

incorporated the use of Gates Glidden #2 , #3, and #4
drills to help gain straight line access to the apical third Comparison o f Gates Glidden Drills
of the canal (Figure 4-6). 44,48,49 This facilitated the plac- with Standardized Files
ing of a tapered instrument into the canal; previously,
progress toward the apex was impeded when the diam-
eter of the tapered file exceeded the diameter of the cylin-
drical canal. Before using Gates Glidden drills, the clini-
cian facilitates access to the canal orifice by removing
overlying dentinal structure (Figure 4-7).
Coronal enlargement before apical preparation pro-
vides straighter access to the apical region; eliminates in-
terferences and canal irregularities in the coronal two
thirds of the root; permits deeper placement of instru-
ments that otherwise might not go to length; removes the
bulk of tissue, debris, and microorganisms; and allows
deeper penetration of irrigating solutions. One disad- After lubricating the chamber with an irrigant, a #2 bur
vantage of coronal enlargement and the use of Gates is placed into the canal orifice and run at medium speed
Glidden drills is the excessive removal of tooth structure. with a light force. The deepest penetration of the canal
A comparison of the size of the Gates Glidden drills to occurs with the #2 Gates Glidden. Next, the #3 Gates
standardized files is presented in Box 4-1. The routine Glidden is used at a shorter length and directed to the
use of #5 and #6 Gates Glidden instruments results in perimeter of the canal (Figure 4-8). Finally, a #4 Gates
excessive removal of tooth structure and increases the Glidden is used to the depth of the head of the bur to fi-
incidence of stripping perforations in the furcation area. nalize the straight line access. This step helps establish
The Gates Glidden drills are used after a size 25 the space for the hand files to reach the apical third
MAF can be introduced to the corrected working length. without interference.
72 Color Atlas o f Endodontics
FIGURE 4-8 Although the #1 and #2 Gates Glidden drills are
used to remove dentin uniformly from the canal walls, the #3 to
#6 drills have the strength to permit lateral movement and selec-
tive removal of tooth structure away from the furcation or danger
zone. Directing the Gates Glidden drill toward the line angles in
molars enhances straight line access and reduces the risk of strip-
ping perforations.
STEP-DOWN TECHNIQUE. A variation on the timing of
the use of the Gates Glidden drills was presented by
Goerig.50 He advocated using a #4 round bur to establish
coronal access, followed by Hedstrom files size 15, 20,
and 25 in the coronal two thirds of the estimated canal
length. Only a filing or rasping motion is used and apical
patency is maintained with a size #10 K-file. Patency
should be checked as necessary. A #2 Gates Glidden drill
is then used 14 to 16 mm in the canal, a #3 Gates Glidden
is inserted 11 to 13 mm into the canal, and a #4 Gates
Glidden is used as needed by the canal size. This proce-
dure allows straight line access to the apical one third be-
fore active instrumentation takes place, thereby eliminat-
ing many of the interferences usually encountered.
Several studies have supported this general technique
with respect to reducing procedural accidents such as
stripping perforations and apical transportation.
Greater apical enlargement without apical transporta-
tion can be achieved if coronal obstructions are elimi-
nated. 51,52 One group of authors demonstrated signifi-
cant improvement in tactility with files following
coronal pre-flaring.-53 In a direct comparison between
pre-flaring before the establishment of working length
and flaring after working length establishment, Morgan
and Montgomery found that the "crown-down pres-
sureless" technique resulted in a rounder canal shape
significantly more often than when the step-back flaring
technique was used. 54
PASSIVE STEP-BACK TECHNIQUE. The passive step-back
technique developed by Torabinejad uses a combination
of hand and rotary instruments to develop a flared
preparation.55 This technique provides gradual enlarge-
ment of the root in an apical to coronal direction with-
out the application of force and reduces the risk of pro-
cedural accidents caused by transportation. It is a
modification of the canal bed enlargement advocated by
Schilder, in which shaping consisted of placing instru-
ments larger than the MAF to a point of first binding
and then using a reaming action to enlarge the coronal
portion of the canal. This permits the morphology
(shape) of the canal to influence the preparation and dif-
fers from the arbitrary step-back procedures of millime-
ter increments. 2
The passive step-back technique involves establish-
ing a corrected working length using a #15 file. The #15
file is inserted to the corrected working length with light
pressure and then rotated one eighth to one quarter turn.
Additional K-type files between #20 and #40 are then in-
serted passively as far as they will go and rotated one
eighth to one quarter turn with light pressure. Gates
Glidden drills (#2 to #4) are then used coronally, and
apical preparation is accomplished. Narrow, curved
canals should not be enlarged beyond a #25 or #30 file.
The apical portion of the canal is prepared by placing se-
quentially larger files passively in the canal and rotating
them one eighth to one quarter turn. Advantages to the
passive step-back technique include knowledge of canal
morphology, removal of debris and minor canal ob-
structions, and a gradual passive enlargement of the
canal in an apical to coronal direction. With this process
the canal morphology influences the preparation shape.
The passive step-back technique has also been advo-
cated for use with ultrasonic instruments after the work-
ing length is established. Copious irrigation with sodium
hypochlorite is suggested. A #15 endosonic file is pas-
sively placed in the canal, driven ultrasonically for 30
seconds, and worked circumferentially. Hand instru-
ments are then introduced into the canal. This alternat-
ing use of ultrasonic and hand instruments is performed
in a stepwise fashion until a mildly flared canal is
achieved. A #2 Gates Glidden drill is then inserted until
it binds, withdrawn 1 to 1.5 mm, and activated with an
up-and-down motion. A #3 Gates Glidden drill is used
after irrigation with 2.5% sodium hypochlorite. Work-
ing length is then reestablished, and the apical prepara-
tion is completed.
BALANCED FORCE TECHNIQUE. The balanced force tech-
nique was developed and introduced by Roane. 56 This
technique employs a unique instrument tip design and
method of cutting dentin. One principle of the balanced
 Chapter Four Canal Preparation 73

A B

FIGURE 4-9 A, In the balanced force technique the file is placed to working length and rotated
clockwise 90 degrees with light pressure to engage dentin. B, The file is then rotated counterclock-
wise 120 degrees while apical pressure is maintained to cut and enlarge the canal. Debris is removed
with a final clockwise rotation that loads the flutes with loosened debris.

force technique is the recognition that traditional K-type
files have pyramidal tips with cutting angles that can be
quite aggressive with clockwise rotation. Roane modi-
fied traditional K-type files to reduce the transitional an-
gle at the tip, producing a parabolic shape that alters the
ability of the instrument to respond to distortion in a
concentrated area. Forces are distributed over the file
flutes and are not concentrated at the tip. The subse-
quent Flex-R (Union Broach, York, PA) file has a unique
"safe" tip design with a guiding land area behind the tip
that allows the file to follow canal curvature without
binding in the outside wall of the curved canal. In addi-
tion, Roane advocated the use of a triangular cross-
sectional instrument because the decreased mass of the
instrument and its deeper cutting flutes improve flexibil-
ity and decrease the restoring force of the instrument
when placed in a curved canal.
Before instrumentation, #1 to #6 Gates Glidden drills
are used for straight line access. In balanced force in-
strumentation, the files cut in both clockwise and coun-
terclockwise rotation. Instruments rotated in a clockwise
direction tend to move apically as the instrument en-
gages the dentinal wall, pulling the instrument into the
canal. Instruments rotated in a counterclockwise direc-
tion tend to move coronally or out of the canal. Rota-
tion of the instrument 120 degrees ensures that each
blade reaches the beginning position of the initial blade
and enlarges the entire canal.
In the balanced force technique the file is placed to
working length and rotated clockwise 90 degrees with
light pressure to engage the dentin (Figure 4-9). The file
is then rotated counterclockwise 120 degrees while api-
cal pressure is maintained to cut and enlarge the canal.
Further counterclockwise rotation ensures enlargement
of the full diameter of the canal. A final clockwise rota-
tion then loads the flutes of the file with loosened debris,
and the file is withdrawn. An advantage to the technique
is the ability to manipulate the files at any point in the
canal without ledging or blockage.
In small, curved canals, one study using extracted
teeth demonstrated that the apical canal preparation up
to a size 40 MAF remained centered in the original canal
space in 80% of the cases . 57 Another study found less
debris extrusion with the balanced force technique com-
pared with step-back filing and endosonic filing.58
Overall, the technique has been shown to reduce
canal transpiration compared with other techniques .59-61
However, one shortcoming of the technique is that the
74 Color Atlas o f Endodontics
use of #5 and #6 Gates Glidden drills results in a higher
incidence of stripping perforations. Also, no clinical stud-
ies have demonstrated superior success rates over other
techniques. 62
NICKEL-TITANIUM INSTRUMENTS. In 1988, researchers at
Marquette University published a study examining en-
dodontic files that had been fabricated from nitinol or-
thodontic wire for use as hand instruments. 63 Nickel-
titanium (nitinol) alloy possesses a modulus of elasticity
that is one fourth to one fifth that of stainless steel and
has a wide range of elastic deformation, resulting in
greater flexibility. An advantage of this increased flexibil-
i ty is that the file follows the canal curvature with less de-
formation of the curvature during enlargement. 64 Better
instrument centering in the apical preparation has been
reported for both engine-driven and hand-manipulated
nickel-titanium instruments. 61,66 A disadvantage of in-
creased flexibility is the inability to pre-curve the file for
introduction into canals of posterior teeth when the size
of the interocclusal opening is decreased. Because of its
greater elasticity, the cutting efficiency of nickel-titanium
files may be reduced with clinical use compared with
stainless steel. 67-69 Therefore, to take advantage of the
properties of nickel-titanium files, engine-driven instru-
ments have been developed. The present nickel-titanium
instruments incorporate a U-shaped groove with a flat
land area. When the instrument is rotated, the flutes
plane the canal wall while the land area keeps the instru-
ment centered, especially in fine, curved canals.70 -73
As might be expected, instrumentation techniques
with the newer nickel-titanium files have been evolu-
tionary as well as revolutionary. After the initial intro-
duction of nickel-titanium files, step-back preparations
using hand files and engine-driven files were common.
Dentsply, Tulsa Dental (Tulsa, OK) has always advo-
cated the use of a "crown down" technique with their
Profile brand instruments. However, changes in instru-
ment design over the past several years have resulted in
at least three different sets of instruments (Profile, Quan-
tec, and Lightspeed) and subsequent instrumentation
techniques (see Chapter 5).
EVALUATION OF CANAL PREPARATION
TECHNIQUES
Several techniques have been advocated for the evalua-
tion of root canal debridement and enlargement. Plastic
blocks with uniform, preformed curves have been used
by many researchers to evaluate the appearance of the
canal before and after the instrumentation tech-
nique. 26,27,42,74 This methodology provides some answers
to general questions of instrument action or irrigation
patterns, but does not address concerns regarding the
starting point for teeth with cross-sections and curves
that are far more complex than the circular artificial
canal. In addition, these studies do not provide informa-
tion regarding the cleaning phase of treatment.
Some researchers have performed histologic evalua-
tions of remaining debris or pulp tissue while relying on
estimates for dentinal walls that were planed. 44,7 5 , 76 The
limitations of these studies lie in the fact that no method
exists to "pre-test" for existing debris and therefore all
results are post-test estimates. These histologic studies
are extremely time-consuming and can also have arti-
facts from processing errors. They do not lend them-
selves to evaluation of the complete length of the canal.
An attempt at a "pre-test, post-test" model was de-
veloped by Bramante et a l.77 The model consisted of
teeth that were mounted in dental stone or acrylic that
could then be sectioned and reassembled in a jig. 77-79
This allows photographs or micrographs of the canal to
be made before instrumentation. Post-instrumentation
evaluation can then compare several of the aforemen-
tioned criteria with the differences found between the
two photographs or micrographs. Limitations include
tooth loss resulting from sectioning, a lack of precision
in the instruments used to compare before and after in-
strumentation, and an inability to observe the entire
length of the canal.
Recently a technique has been developed that elimi-
nates many of the shortcomings of the previous studies.
A three-dimensional, nondestructive technique for de-
tailing root canal geometry by means of high-resolution
tomography has been developed. 80 A micro-computed
tomography scanner (microCT, cubic resolution of 34
microns) is used to record the precise canal anatomy be-
fore and after instrumentation. A three-dimensional
analysis of root canal geometry by high-resolution com-
puted tomography is then performed. The first report of
this technique studied hand instrumentation with K-flex
files, Lightspeed rotary instruments, Profile .04 taper ro-
tary instruments, and GT rotary files. They found no dif-
ferences in volume removed, canal straightening, and the
amount of untreated area among the techniques. Signifi-
cantly, they reported that all the techniques left more
than a third of the canal surface uninstrumented. 81 This
advance in the technology of canal preparation evalua-
tion leads to only one conclusion-all instrumentation
techniques fail to debride 100% of the canal space.
CLINICAL SIGNIFICANCE
Canal preparation is only one phase of endodontic treat-
ment. Although current instruments and techniques vary,
straight line access, step-back instrumentation, and api-
cal preparation are three common concepts (Figure
4-10). Major differences in technique involve the order
i n which each step is accomplished and the instruments
used. Although clinicians may use a specific process rou-
tinely, each case is unique and astute clinicians modify
their techniques when necessary to achieve success.
 Chapter Four
FIGURE 4-10 Canal preparation can be thought of in three
phases: 1) straight line access, 2) step-back instrumentation, and
3) apical preparation. Although the instruments used and order of
these three steps may vary, the end result should be a tapered
canal in its original position with a small apical opening.
The clinical success that occurs in endodontic prac-
tice far exceeds 66%, which is the theoretical predicted
success if ddbridement is the only criterion for predict-
ing success. The importance of adequately sealing the
canal after ddbridement and then sealing the coronal
space are integral parts of the process and undoubtedly
contribute to the reported success rates in practice.82 -86
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3. Rosenfeld EE James GA, Burch BS: Vital pulp tissue response to
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3(5):194, 1977.
13. Cecic PA, Peters DD, Grower MF: The comparative efficiency of fi-
nal endodontic cleansing procedures in removing a radioactive al-
bumin from root canal systems, Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 58(3):336, 1984.
14. Baumgartner JC, Mader CL: A scanning electron microscopic eval-
uation of four root canal irrigation regimens, J Endod 13(4):147,
1987.
15. Svec TA, Harrison JW The effect of effervescence on debridement
of the apical regions of root canals in single-rooted teeth, J Endod
7(7):335, 1981.
16. Gambarini G: Shaping and cleaning the root canal system: a scan-
ning electron microscopic evaluation of a new instrumentation and
irrigation technique, J Endod 25(12):800, 1999.
17. Behrend GD, Cutler CW, Gutmann JL: An in-vitro study of smear
layer removal and microbial leakage along root-canal fillings, Int
Endod J 29(2):99, 1996.
18. Takeda FH et al: A comparative study of the removal of smear
layer by three endodontic irrigants and two types of laser, Int En-
dod J 32(1):32, 1999.
19. Yamaguchi M et al: Root canal irrigation with citric acid solution,
J Endod 22(1):27, 1996.
20. Wayman BE et al: Citric and lactic acids as root canal irrigants in
vitro, J Endod 5(9):258, 1979.
21. Grahnen H, Krasse B: The effect of instrumentation and flushing
of non-vital teeth in endodontic therapy, Odontol Rev 14:167,
1963.
22. Bystrom A, Sundqvist G: Bacteriologic evaluation of the efficacy of
mechanical root canal instrumentation in endodontic therapy,
Scand J Dent Res 89(4):321, 1981.
23. Bystrom A, Claesson R, Sundqvist G: The antibacterial effect of
camphorated paramonochlorophenol, camphorated phenol and
calcium hydroxide in the treatment of infected root canals, Endod
Dent Traumatol1(5):170, 1985.
24. Ram Z: Effectiveness of root canal irrigation, Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 44(2):306, 1977.
25. Kahn FH, Rosenberg PA, Gliksberg J: An in vitro evaluation of
the irrigating characteristics of ultrasonic and subsonic handpieces
and irrigating needles and probes, J Endod 21(5):277, 1995.
26. Krell KV, Johnson RJ, Madison S: Irrigation patterns during ul-
trasonic canal instrumentation. Part I. K-type files, J Endod
14(2):65, 1988.
27. Krell KV, Johnson RJ: Irrigation patterns of ultrasonic endodontic
files. Part II. Diamond-coated files, J Endod 14(11):535, 1988.
28. American Dental Association, Council on Dental Materials: New
American Dental Association specification no. 28 for endodontic
files and reamers, J Am Dent Assoc 93:813, 1976.
29. American Dental Association, Council on Dental Materials:
ANSI/ADA specification no. 58 for root canal files, type H (Hed-
strom), J Am Dent Assoc 104:88, 1982.
30. American Dental Association, Council on Dental Materials, In-
struments and Equipment: Revised ANSI/ADA specifications no.
28 for root canal files and reamers, type K, and no. 58 for root
canal files, type H (Hedstrom), J Am Dent Assoc 118:239, 1989.
31. American National Standard/American Dental Association, Coun-
cil on Standards: Proposed specification no. 95 for root canal en-
largers, Chicago, 2000, American Dental Association.
76 Color Atlas o f Endodontics
32. Luebke NH, Brantley WA: Physical dimensions and torsional
properties of rotary endodontic instruments. 1. Gates Glidden
drills, J Endod 16(9):438, 1990.
33. Luebke NH, Brantley WA: Torsional and metallurgical properties
of rotary endodontic instruments. 2. Stainless steel Gates Glidden
drills, j Endod 17(7):319, 1991.
34. Luebke NH et al: Physical dimensions, torsional performance, and
metallurgical properties of rotary endodontic instruments. 3. Peeso
drills, J Endod 18(1):13, 1992.
35. Luebke NH et al: Physical dimensions, torsional performance,
bending properties, and metallurgical characteristics of rotary en-
dodontic instruments. VI. Canal Master drills, J Endod 21(5):259,
1995.
36. Brantley WA et al: Performance of engine-driven rotary endodon-
tic instruments with a superimposed bending deflection: V. Gates
Glidden and Peeso drills, J Endod 20(5):241, 1994.
37. Ingle JI: A standardized endodontic technique using newly de-
signed instruments and filling materials, Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 14:83, 1961.
38. Haga CS: Microscopic measurements of root canal preparations
following instrumentation, J Br Endod Soc 2(3):41, 1969.
39. Jungmann CL, Uchin RA, Bucher JF: Effect of instrumentation on
the shape of the root canal, J Endod 1:66, 1975.
40. Schneider SW A comparison of canal preparations in straight and
curved root canals, Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 32(2):271, 1971.
41. Clem WH: Endodontics: the adolescent patient, Dent Clin North
Am 13(2):482, 1969.
42. Weine FS, Kelly RF, Lio PJ: The effect of preparation procedures
on original canal shape and on apical foramen shape, J Endod
1(8):255, 1975.
43. Coffae KP, Brilliant JD: The effect of serial preparation versus non-
serial preparation on tissue removal in the root canals of extracted
mandibular human molars, J Endod 1(6):211, 1975.
44. Walton RE: Histologic evaluation of different methods of enlarg-
ing the pulp space, J Endod 2:304, 1976.
45. Weine FS et al: Pre-curved files and incremental instrumentation
for root canal enlargement, J Can Dent Assoc 36(4):155, 1970.
46. Weine FS, Kelly RF, Bray KE: Effect of preparation with en-
dodontic handpieces on original canal shape, J Endod 2(10):298,
1976.
47. Johnson WT: Instrumentation of the fine curved canals found in
the mesial roots of maxillary and mandibular molars, Quintes-
sence Int 17(5):309, 1986.
48. Weine F: Endodontic therapy, ed 5, St Louis, 1996, Mosby.
49. Mullaney TP: Instrumentation of finely curved canals, Dent Clin
North Am 23(4):575, 1979.
50. Goerig AC, Michelich RJ, Schultz HH: Instrumentation of root
canals in molars using the step-down technique, J Endod
8(12):550, 1982.
51. Abou-Rass M, Frank AL, Glick DH: The anticurvature filing
method to prepare the curved root canal, J Am Dent Assoc
101(5):792, 1980.
52. Leeb J: Canal orifice enlargement as related to biomechanical
preparation, J Endod 9(11):463, 1983.
53. Stabholz A, Rotstein 1, Torabinejad M: Effect of preflaring on
tactile detection of the apical constriction, J Endod 21(2):92,
1995.
54. Morgan LF, Montgomery S: An evaluation of the crown-down
pressureless technique, J Endod 10(10):491, 1984.
55. Torabinejad M: Passive step-back technique. A sequential use of
ultrasonic and hand instruments, Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 77(4):402, 1994.
56. Roane JB, Sabala CL, Duncanson, MG, Jr: The "balanced force"
concept for instrumentation of curved canals, J Endod 11(5 ):203,
1985.
57. Southard DW, Oswald RJ, Natkin E: Instrumentation of curved
molar root canals with the Roane technique, J Endod 13(10):479,
1987.
58. McKendry DJ: Comparison of balanced forces, endosonic, and
step-back filing instrumentation techniques: quantification of ex-
truded apical debris, J Endod 16(1):24, 1990.
59. Sabala CL, Roane JB, Southard LZ: Instrumentation of curved
canals using a modified tipped instrument: a comparison study,
J Endod 14(2):59, 1988.
60. Sepic AO et al: A comparison of Flex-R files and K-type files for
enlargement of severely curved molar root canals, J Endod
15(6):240, 1989.
61. Backman CA, Oswald RJ, Pitts DL: A radiographic comparison
of two root canal instrumentation techniques, J Endod 18(1):19,
1992.
62. Zuolo ML, Walton RE, Imura N: Histologic evaluation of three
endodontic instrument/preparation techniques, Endod Dent Trau-
matol 8(3):125, 1992.
63. Walia HM, Brantley WA, Gerstein H: An initial investigation of
the bending and torsional properties of Nitinol root canal files,
J Endod 14(7):346,1988.
64. Zmener O, Balbachan L: Effectiveness of nickel-titanium files for
preparing curved root canals, Endod Dent Traumatol 11(3):121,
1995.
65. Glossen CR et a1: A comparison of root canal preparations using
Ni-Ti hand, Ni-Ti engine-driven, and K-Flex endodontic instru-
ments, J Endod 21(3):146, 1995.
66. Esposito PT, Cunningham CJ: A comparison of canal preparation
with nickel-titanium and stainless steel instruments, J Endod
21(4):173, 1995.
67. Camps JJ, Pertot WJ: Machining efficiency of nickel-titanium
K-type files in a linear motion, Int Endod J 28(6):279, 1995.
68. Schafer E, Tepel J: Cutting efficiency of Hedstrom S and U files
made of various alloys in filing motion, Int Endod J 29(5):302,
1996.
69. Schafer E, Lau R: Comparison of cutting efficiency and instru-
mentation of curved canals with nickel-titanium and stainless-steel
i nstruments, J Endod 25(6):427, 1999.
70. Harlan AL, Nicholls JI, Steiner JC: A comparison of curved
canal instrumentation using nickel-titanium or stainless steel
files with the balanced-force technique, J Endod 22(8):410,
1996.
71. Coleman CL, Svec TA: Analysis of Ni-Ti versus stainless steel in-
strumentation in resin simulated canals, J Endod 23(4):232, 1997.
72. Short JA, Morgan LA, Baumgartner JC: A comparison of canal
centering ability of four instrumentation techniques, J Endod
23(8):503, 1997.
73. Carvalho LA, Bonetti 1, Borges MA: A comparison of molar root
canal preparation using stainless-steel and nickel-titanium instru-
ments, J Endod 25(12):807, 1999.
74. Wildey WL, Senia ES: A new root canal instrument and instru-
mentation technique: a preliminary report, Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 67(2):198, 1989.
75. Hill RL, del Rio CE: A histological comparison of the canal wall
planing ability of two new endodontic files, J Endod 9(12):517,
1983.
76. Reynolds MA et al: An in vitro histological comparison of the
step-back, sonic, and ultrasonic instrumentation techniques in
small, curved root canals, J Endod 13(7):307, 1987.
77. Bramante CM, Berbert A, Borges RP: A methodology for evalua-
tion of root canal instrumentation, J Endod 13(5):243, 1987.
78. Calhoun G, Montgomery S: The effects of four instrumentation
techniques on root canal shape, J Endod 14(6):273, 1988.
79. Leseberg DA, Montgomery S: The effects of Canal Master, Flex-R,
and K-Flex instrumentation on root canal configuration, J Endod
17(2):59, 1991.
 Chapter Four
80. Peters OA et al: Three-dimensional analysis of root canal geome-
try by high-resolution computed tomography, J Dent Res
79(6):1405, 2000.
81. Schoenberger K, Laib A, Peters O: Four NiTi canal preparation
techniques evaluated by micro computed tomography, Oral Res
Poster Res Abstr p 1, March 2000.
82. Sivers JE, Johnson WT: Restoration of endodontically treated
teeth, Dent Clin North Am 36(3):631, 1992.
83. Orstavik D: Time-course and risk analyses of the development and
healing of chronic apical periodontitis in man, Int Endod J
29(3):150, 1996.
Canal Preparation 77
84. Sjogren U et al: Influence of infection at the time of root filling on
the outcome of endodontic treatment of teeth with apical peri-
odontitis [published erratum appears in Int Endod J 31(2):148,
1998], Int Endod J 30(5):297,1997.
85. Sundqvist G et al: Microbiologic analysis of teeth with failed en-
dodontic treatment and the outcome of conservative re-treatment,
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 85(1):86,
1998.
86. Zmener O, Banegas G: Clinical experience of root canal filling by
ultrasonic condensation of gutta-percha, Endod Dent Traumatol
15(2):57, 1999.
TEB SINA CHEHR
(4070932 - 6418770)
80 Color Atlas of Endodontics
FIGURE 5-1 A high-torque, low-rpm electric handpiece designed
for nickel-titanium rotary instrumentation.
To facilitate rotary instrumentation, high-torque low-
RPM handpieces have been developed. Electric (Figure
5-1) and air-driven handpieces (Figure 5-2) are available
and perform equally well in regard to file distortion and
breakage, with the speed of operation being the most sig-
nificant factor in these failures .28 The type of handpiece
used does not appear to be as important as the force ap-
plied and the operational speed. Some electric hand-
pieces can sense instrument stress and reverse when their
li mits are exceeded. Quiet operation is an additional ad-
vantage of electric handpieces.
The sequential insertion of files with a standardized
. 02 taper ensures that each file inserted into the canal has
maximal contact with the canal walls throughout the
working length of the instrument. This contact induces
frictional resistance on rotation. The principle of se-
quential insertion applies to rotary canal preparation
techniques. However, nickel-titanium instruments can
separate if they are stressed during rotation. As the
surface area of contact between the file and the canal
wall increases, so too does the frictional resistance and
the force required to rotate the file, thereby increasing
the potential for fracture. A variety of tapered nickel-
titanium instruments used in a crown-down method re-
duces the contact area and therefore the frictional resis-
tance and stress. In addition, the flute design of the in-
struments aids in removal of debris and the decreased
cutting length of the files reduces stress.
Nickel-titanium instruments fail at a lesser torque
compared with stainless steel instruments of the same
size. 29 This means nickel-titanium fails under lighter
pressure. Although stainless steel files often give a visual
clue that stress has occurred, nickel-titanium files fail
without warning. Inspection of the files should be per-
formed with magnification. 28
FIGURE 5-2 A high-torque, low-rpm air-driven handpiece de-
signed for nickel-titanium rotary instrumentation.
Most rotary systems employ a crown-down ap-
proach. With this technique the canal is cleaned and
shaped as the coronal structure is removed. The crown-
down technique provides space for succeeding instru-
ments to pass unobstructed to the unprepared apical por-
tion of the root. As coronal space is created, interferences
are removed. Therefore when the radicular portion of the
canal is prepared, the instruments tend to center in the
canal and remove dentin uniformly. This reduces proce-
dural errors such as ledging, zipping, and apical perfora-
tion. An additional advantage to the crown-down ap-
proach is that it causes less extrusion of debris through
the apex.30,31 Evidence suggests that clinicians should ex-
ercise care when using .04 tapered instruments because
file contact with dentin is concentrated at the tip. 32
PROFILE INSTRUMENTS
The nickel-titanium files manufactured by Dentsply/Tulsa
Dental (Tulsa, OK) exhibit a cross-sectional configura-
tion consisting of three radial lands. These keep the in-
struments centered in the canal and plane or scrape the
canal walls during use . 33 U-shaped flutes that remove de-
bris separate the radial lands. A non-cutting pilot tip pro-
vides guidance to the instruments.
Profile 29 Series
The Profile 29 series of instruments has a progressive
29% increase in diameter size at D 0 . The first eight files
replace the 11 files necessary with the traditional size
0.10 through 0.60 files. The instruments are better
spaced, with more instruments in smaller sizes (where
procedural errors occur) and fewer large instruments.
The transition between sizes is enhanced by a more grad-
ual increase in diameter. The clinician should keep in
 Chapter Five Rotary Canal Preparation 81

FIGURE 5-3 Profile .04 tapered instruments, sizes 15 to 40. FIGURE 5-4 Scanning electron microscopic view of 25/.02 (bot-
tom), 25/.04 (middle), and 25/.06 (top) Profile instruments.

FIGURE 5-5 Profile 15/.02 (top), 15/.04 (middle), and 15/.06 (bottom) i nstruments. Note the
standardized tip diameter and increased taper of the files.

mind that the percent difference in diameter from a tra-
ditional size 10 file and a size 15 file is 50%, whereas the
difference between a size 55 and a size 60 instrument is
only 9%. The first five Profile 29 instruments exhibit nar-
rower diameters at D0 compared with traditional files.
Profile.02, .04, and.06 Tapered
Instruments
The Profile .02, .04, and .06 series of instruments are
manufactured to International Standards Organization
(ISO) standards with regard to tip diameter (Figure
5-3). The instruments differ only in regard to taper
( Figure 5-4). The 25/.02 file has a diameter at D16 of
0.57 mm, the 25/.04 instrument has a diameter at D 16
of 0.89 mm, and the 25/.06 instrument has a diameter
of 1.21 mm at D 16 ( Figure 5-5). As the taper of the in-
struments used increases, the shape of the preparation
becomes fuller.30 The instrument design incorporates
radial lands in the flute design (Figure 5-6). In cases of
fine, curved canals the .04 (Figure 5-7) and .06 (Fig-
ure 5-8) tapered instruments produce excellent clinical
results.
82 Color Atlas of Endodontics

FIGURE 5-6 Scanning electron microscopic view of a Profile 25/.04 instrument with radial lands.

FIGURE 5-7 Preoperative (A) and postoperative (B) radiographs of a right mandibular first molar
prepared with Profile .04 tapered instruments.

FIGURE 5-8 Preoperative (A) and postoperative (B) radiographs of a right mandibular first molar
prepared with Profile .06 tapered instruments.
 Chapter Five
Greater Taper Series
The original Profile GT starter kit consists of the stan-
dard GT series of instruments, Profile .04 tapered files,
and the accessory GT instruments. The standard series
is composed of three instruments with 0.06-, 0.08-,
and 0.10-mm tapers. The tip diameter of these files re-
mains constant at 0.20 mm. The maximum file diame-
ter is 1.0 mm (Figure 5-9). The instruments exhibit
variable taper and variably pitched flutes. The GT files
have K-type flute angles at the tip and open, reamer-
type flute angles near the shank to preserve strength.33
This makes the instruments more aggressive and the
bulk of metal provides strength. The flute length de-
creases as the taper increases, and the instruments ex-
hibit radial lands (Figure 5-10). The Profile .04 instru-
ments have files with tip diameters of 0.20, 0.25, 0.30,
and 0.35 mm. The accessory GT series has three in-
struments that are employed when apical diameters ex-
ceed 0.3 mm. These instruments can also be used to
enlarge the coronal portion of smaller canal systems.
The instruments exhibit a common taper of 0.12 mm
and the same maximum file diameter of 1.5 mm. The
three accessory GT instruments have varied tip diame-
ters of 0.35, 0.50, and 0.70 mm. Typically used in
large canals, their increased taper and reduction in
flute length on the shaft minimize the area of contact
with dentin and subsequent potential for fracture. The
GT accessory series tends to produce parallel canal
walls coronal to the flutes because of the fixed maxi-
mum diameter and short length of the flutes.
FIGURE 5-9 Files of greater taper. Standard Profile GT files (Sil-
ver 20/.06, Gold 20/.08, Red 20/.10) and Profile GT accessory
files (Green 35/.12, Brown 50/.12, and Gold 70/.12).
Rotary Canal Preparation 83
A technique advocated by the manufacturer of the
Profile GT starter kit (Figure 5-11) involves using the
20/.10 (red), 2008 (yellow), and 20/.06 (white) tapers
sequentially in a crown-down fashion at 300 rpm. Each
instrument is used until resistance is encountered. When
the files have reached one half to two thirds of the esti-
mated root length, the clinician can determine the work-
ing length. Profile .04 tapers with standardized tip di-
ameters 35/.04 (green), 30/.04 (blue), 25/.04 (red), and
20/.04 (gold) are then employed in a crown-down man-
ner (Figure 5-12). They should be operated at 150 rpm . 27
Clinicians should exercise care when using the .04 ta-
pered instruments because evidence suggests that the
area of file contact during use of these instruments is at
the tip. 34 For canals with large apical diameters the ac-
cessory GT series can be employed.
Recent developments to the original greater taper
files include improved flute geometry; the creation of
13-mm instruments for easy introduction in posterior
teeth; the development of the 20, 30, and 40 Series
ProSystem GT files (each with tapers of 0.04, 0.06, 0.08,
and 0.10 mm to facilitate shaping small, medium, and
large canals); and modifications to the 35/.12 accessory
file that decrease the maximum shank diameter from 1.5
to 1.25 mm so the instrument can be used in the large
canals of molars (palatal canals of maxillary molars and
distal canals of mandibular molars ).35 In addition, a
standardized marking system has been introduced for
easy identification of the taper and tip configuration of
the instruments. The standard series of GT files was
FIGURE 5-10 Scanning electron microscopic view of a Profile
GT instrument.
FIGURE 5-11 A, Profile GT starter kit. From left to right: Red 20/.10, Gold, 20/.08, Silver 20/.06,
Green 35/.04, Blue 30/.04, Red 25/.04, Gold 20/.04. Profile GT accessory files, from bottom to
top: Green 35/.12, Brown 50/.12, and Gold 70/.12. B, The ProSystem 20 series. The instrument tips
are 0.20 mm and the instruments have (from top to bottom) tapers of .10, .08, .06, and .04. Note
the color coding for tip diameter and markings for instrument taper. Each ring represents a taper of
0.02 mm. The ProSystem 30 and 40 series instruments are similar, with tip diameters of 0.30 and
0.40 mm, respectively. C, The ProSystem GT accessory series consists of instruments with (from top
to bottom) tip diameters of 0.70 mm, 0.50 mm, and 0.35 mm. The taper is 0.12 mm for each in-
strument, as designated by the six rings.

FIGURE 5-12 Preoperative (A) and postoperative (B) radiographs of a left mandibular second mo-
l ar prepared with the Profile GT Starter Kit.
 Chapter Five Rotary Canal Preparation
modified to include the .04 tapered instrument in addi-
tion to the 0.06-, 0.08-, and 0.10-mm tapers.
The crown-down technique with the new ProSystem
GT files is designed to provide a uniform predefined shape
to the prepared canal while reducing the potential for pro
cedural errors. 35 Because each case is unique, a pretreat-
ment assessment of the final size and shape of the canal is
required. The largest file projected for use at the working
length, termed the shaping objective file, depends on canal
anatomy and morphology. 35 This preclinical assessment
can be modified during the procedure as more accurate
information on canal morphology is obtained.
The primary objective in shaping is to develop a con-
tinuous funnel from the orifice to the corrected working
length. Establishing adequate taper during the shaping
process facilitates obturation and ensures that resistance
form is present for obturation. The process begins with
an assessment of the canal size and shape. Although gen-
eral guidelines are presented in Table 5-1, canal size de-
pends on many factors and the clinician should analyze
each tooth as projected on a parallel preoperative radio-
graph. The initial series of instruments can then be se-
lected based on this assessment (Table 5-2).
For cases with small canals, shaping begins with
straight-line access to the canal orifice. The canal is then
negotiated with standardized 08/.02 and 10/.02 ISO ta
pered files. If the small files fail to negotiate the canal,
the clinician can use a passive step-back procedure to
create coronal space for tapered #8 and #10 instruments.
The 20/.10 GT file can then be used with light pressure.
When the file can progress no further, the 2008 GT file
is used. This instrument is followed by the GT 20/.06
and then the GT 20/.04. The crown-down process con-
tinues until the desired shape has been achieved.
After performing a crown-down preparation with
ProSystem GT files, the clinician must evaluate the canal
to ensure that adequate taper has been established. This
process is termed apical gauging and is accomplished by
using .02 tapered standardized stainless steel instru-
ments." Because of the coronal taper established by the
GT files, the standardized ISO instruments bind only at
their tips. The placement of a size #20 standardized ISO
85
file to the corrected working length and the confirmation
of file binding confirm that the apical terminus has a di-
ameter of 0.2 mm. Adequate taper can then be con-
firmed by placing size #25 and #30 files into the canal to
detect binding short of the corrected working length.
When the size #20 file goes beyond the corrected
working length or binding fails to occur after shaping
with GT files, the apical size of the canal is greater than
0.2 mm. Successively larger instruments are then placed
until binding occurs. This assessment of the size of the
apical terminus indicates which ProSystem GT series
should be used at the corrected working length to estab-
lish adequate taper. The 30 series GT files, the 40 series
GT files, and the accessory series GT files are useful in
these cases. After using additional GT files, the clinician
should perform apical gauging and confirmation of ta-
per to ensure the presence of resistance before obtura-
tion. For medium and large canals the process of apical
gauging 1S the same, but larger instruments consistent
with the increased tip diameter are employed.
Files of greater taper are also manufactured as hand
instruments. These are usually used in conjunction with
rotary instruments and produce the same standardized
shape during root canal preparation.
The use of a combination of GT rotary and hand in-
struments is an option. Hand files may be used for
86 Color Atlas o f Endodontics
FIGURE 5-13 The Quantec Series of instruments, from left to right: 15/.02, 25/.02, 25/.03,
25/.04, 25/.05, 25/.06, 25/.08, 25/.10, 25/.12, and 25/.06.
preparation of the apical portion of the canal after coro-
nal use of rotary instruments. Some clinicians employ
traditional hand preparation techniques, including the
use of Gates Glidden drills, to prepare the radicular
space and then use rotary instruments to establish the fi-
nal shape (taper). The use of GT rotary instruments as a
finishing technique enhances the selection of the master
cone and facilitates obturation.
ProSystem GT files facilitate obturation with prede-
fined gutta-percha points during warm vertical conden-
sation. Pluggers are available with the System B heat
source that are consistent with the taper of the prepara-
tion produced by rotary instruments. The uniform taper
of the prepared canal and the correlation of the gutta-
percha and the plugger to the preparation enhance the
hydraulics of warm vertical compaction.
In addition, the ProSystem GT technique combines
the use of rotary files with GT obturators. These carrier-
based gutta-percha obturators are integrated with the
appropriate size rotary files.
Quantec Series
The Quantec series of instruments consists of 10 files
made of nickel-titanium (Figure 5-13). The instruments
are designed to be used in a high-torque, slow-speed
handpiece at 340 RPM. The design of the instruments
and the sequence of their use limit the contact surface of
the instrument with the canal wall. This is accomplished
primarily by the different tapers incorporated into the
instruments. The instruments differ from the Profile and
Lightspeed instruments (Lightspeed, San Antonio, TX)
in that they have a slightly positive rake angle to the cut-
ting flute (Figure 5-14).
The primary Quantec technique employs a three-
step process of early orifice enlargement, apical prepa-
ration, and merging of the orifice enlargement with
apical preparation. 34 An operational speed of 340
RPM is recommended. Orifice enlargement is accom-
plished with the No. 1 instrument, which has a size 25
tip and exhibits a .06 taper (25/.06). The file is pas-
sively advanced in 1-mm increments until pressure is
necessary to advance the instrument. Stage two con-
sists of apical preparation. The No. 2 Quantec file
with a size 15 tip and conventional .02 taper is used
to reach the estimated working length. After establish-
ing the corrected working length, the clinician uses the
No. 3 file 20/.02 and the No. 4 file 25/.02 at length.
Stage three consists of merging the coronal and apical
preparations by flaring the body of the canal. The in-
struments used in this treatment process all have size
25 tips. The instruments differ in that each file has an
increasing taper. The No 5 file has a .03 taper, the No.
6 file has a .04 taper, the No. 7 file has a .05 taper, and
the No. 8 file has a .06 taper. Each instrument is used
 Chapter Five
FIGURE 5-14 A scanning electron microscopic view of a Quan-
tec instrument.
FIGURE 5-16 The Lightspeed series of files.
sequentially to working length. The final two files are
used to finish cases when a larger apical preparation is
desired. The No. 9 file has a size 40 tip with a conven-
tional .02 taper and is used approximately 1 mm short
of working length. The No. 10 instrument has a size
45 instrument tip and a .02 taper. This instrument is
used circumferentially to blend irregularities and canal
i mperfections.
An alternative technique employs a crown-down tech-
nique with a sequence of No. 8, No. 7, No. 6, No. 5, No.
4, and No. 3 files. The Quantec Flare (Analytic Endodon
tics, Sybron Dental Specialties, Orange, CA) series of in-
struments can be used to facilitate coronal flaring. These
instruments have a size 25 tip and tapers of 1.2, 1.0, and
. 08; they are used sequentially in a crown-down approach.
Advantages to the crown-down technique include re-
duction of procedural errors, a more uniform prepara-
tion and canal shape, coronal removal of debris, reduc
tion of stress on the instruments and operator, and
improved efficiency.
Rotary Canal Preparation 87
FIGURE 5-15 A scanning electron microscopic view of a Light-
speed instrument. Note the radial l ands and non-cutting pilot tip.
Lightspeed
Lightspeed nickel-titanium instruments are similar in ap-
pearance to Gates Glidden drills. The U-file design in-
corporates radial lands, a neutral rake angle, and a non-
cutting pilot tip (Figure 5-15). The instruments are
manufactured with tip diameters from 20 to 100, with
half sizes from 22.5 to 65 (Figure 5-16). The parallel
non-cutting shaft provides flexibility and limits the sur-
face area of contact during rotation. The instruments are
used at 750 to 2000 RPM, a relatively high speed com-
pared with the Profile and Quantec systems.
The Lightspeed technique requires coronal flaring
with Gates Glidden drills, as well as establishment of
working length. Apical patency is established with a size
15 file. After this the clinician establishes the size of the
canal at working length by placing Lightspeed instru-
ments into the canal, beginning with the size #20 and pro-
gressing sequentially through larger sizes, until the first
instrument to bind at length is determined. This pro-
cedure establishes canal size before preparation and is
88 Color Atlas o f Endodontics
designated the first Lightspeed to bind ( FLSB). To speed
the process of finding the FLSB, the manufacturer pro-
vides guidelines for beginning the process for each tooth
group (Table 5-3). Canal preparation begins with the next
largest instrument. Rotation of the instrument should be
continuous at a recommended speed of 750 to 2000
RPM, with 1300 to 2000 RPM being preferred. The in-
struments are gently advanced and withdrawn. After en-
countering resistance the clinician uses a light "pecking"
motion to advance the instrument. Instruments should al-
ways be in motion and never left in one place. Enlarge-
ment of the canal is accomplished by using instruments
in sequential order until the master apical rotary (MAR)
file is reached. The MAR is defined as the Lightspeed in-
strument that requires a minimum of 12 "pecks" to reach
the working length. After reaching the MAR, the clini-
cian uses the next four instruments in a step-back manner
at 1-mm increments. The fifth largest instrument is placed
in the canal until it binds and then advanced apically with
four light pecks. Recapitulation is accomplished with the
MAR. An advantage to the Lightspeed technique is that it
preserves tooth structure because the canal does not be-
come extensively tapered. This minimal tapering pre-
serves dentin and tooth strength.
Lightspeed Guidelines for Establishing the
First Lightspeed Size to Bind (FLSB) and
the Master Apical Rotary (MAR) File
TOOTH TYPE
OR GROUP FLSB MAR
References
1. Turek T, Langeland K: A light microscopic study of the efficacy of
the telescopic and the Giromatic preparation of root canals, J En-
dod 8:437, 1982.
2. Walia H, Brantley WA, Gerstein H: An initial investigation of
bending and torsional properties of nitinol root canal files, J En-
dod 14:346, 1988.
3. Kazemi RB, Stenman E, Spangberg LS: Machining efficiency and
wear resistance of nickel-titanium endodontic files, Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 81:596, 1996.
4. Busslinger A, Sener B, Barbakow F: Effects of sodium hypochlorite
on nickel-titanium Lightspeed instruments, Int Endod J 31:290,
1998.
5. Stokes OW et al: Corrosion in stainless-steel and nickel-titanium
files, J Endod 25:17, 1999.
6. Mize SB et al: Effect of sterilization on cyclic fatigue of rotary
nickel-titanium endodontic instruments, J Endod 24:843, 1998.
7. Canalda-Sahli C, Brau-Aguade E, Sentis-Vilalta J: The effect of
sterilization on bending and torsional properties of K-files manu-
factured with different metallic alloys, Int Endod J 31:48, 1998.
8. Hilt R et al: Torsional properties of stainless steel and nickel-
titanium files after multiple autoclave sterilization, J Endod 26:76,
2000.
9. Zmener O, Balbachan L: Effectiveness of nickel-titanium files for
preparing curved root canals, Endod Dent Traumatol 11:121,
1995.
10. Royal JR, Donnelly JC: A comparison of maintenance of canal
curvature using balanced-force instrumentation with three differ-
ent file types, J Endod 21:300, 1995.
11. Glossen CR et al: A comparison of root canal preparations using
Ni-Ti hand, Ni-Ti engine-driven, and K-Flex endodontic instru-
ments, J Endod 21:146, 1995.
12. Esposito PT, Cunningham CJ: A comparison of canal preparation
with nickel-titanium and stainless steel instruments, J Endod
21:173, 1995.
13. Pertot WJ, Camps J, Damiani MG: Transportation of curved
canals prepared with Canal Master U, Canal Master U NiTi, and
stainless steel K-type files, Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 79:504, 1995.
14. Shadid DB, Nicholls Jl, Steiner JC: A comparison of curved canal
transportation with balanced force versus Lightspeed, J Endod
24:651, 1998.
15. Short JA, Morgan LA, Baumgartner JC: A comparison of canal
centering ability of four instrumentation techniques, J Endod
23:503, 1997.
16. Portenier 1, Lutz F, Barbakow F: Preparation of the apical part of
the root canal by the Lightspeed and step-back techniques, Int En-
dod J 31:103, 1998.
17. Thompson SA, Dummer PM: Shaping ability of Quantec Series
2000 rotary nickel-titanium instruments in simulated root canals:
part 1, Int Endod J 31:259, 1998.
18. Siqueira JF, jr, et al: Histological evaluation of the effectiveness of
five instrumentation techniques for cleaning the apical third of
root canals, J Endod 23:499, 1997.
19. Tucker DM, Wenckus CS, Bentkover SK: Canal wall planning
by engine-driven nickel-titanium instruments, compared with
stainless-steel hand instrumentation, J Endod 23:170, 1997.
20. Dalton BC et al: Bacterial reduction with nickel-titanium rotary
instrumentation, J Endod 24:763, 1998.
21. Shuping GB et al: Reduction of intracanal bacteria using nickel-
titanium rotary instrumentation and various medications, J En-
dod 26:751, 2000.
22. Glickman GN, Koch KA: Twenty-first century endodontics, JADA
131:39S, 2000.
23. Pruett JP, Clement DJ, Carnes DL: Cyclic fatigue testing of nickel-
titanium endodontic instruments, J Endod 23:77, 1997.
 Chapter Five Rotary Canal Preparation
24. Bonetti Filho I et al: Microscopic evaluation of three endodontic
files pre-and postinstrumentation, J Endod 24:461, 1998.
25. Boonrat S et al: Defects in rotary nickel-titanium files after clinical
use, J Endod 26:161, 2000.
26. Deitz DB et al: Effect of rotational speed on the breakage of nickel-
titanium rotary files, J Endod 26:68, 2000.
27. Gabel WP et al: Effect of rotational speed on nickel-titanium file
distortion, J Endod 25:752, 2000.
28. Bortnick KL, Steiman HR, Ruskin A: Comparison of nickel-
titanium file distortion using electric and air-driven handpieces,
J Endod 27:57, 2001.
29. Roane JB: Crown-down nickel-titanium and endodontics, Endod
Pract 2:16, 1999.
30. Hinrichs RE, Walker WA, 111, Schindler WG: A comparison of
amounts of apically extruded debris using handpiece-driven nickel-
titanium instrument systems, J Endod 24:102, 1998.
89
31. Beeson TJ et al: Comparison of debris extruded apically in straight
canals: conventional filing versus Profile .04 Taper series 29, J En-
dod 24:18, 1998.
32. Blum JY, Machtou P, Micallef JP: Location of contact areas on ro-
tary Profile instruments in relationship to the forces developed dur-
ing mechanical preparation on extracted teeth, Int Endod J
32:108,1999.
33. Kanavagh D, Lumley PJ: An in vitro evaluation of canal prepara-
tion using Profile .04 and .06 taper series instruments, Endod Dent
Traumatol 14:16, 1998.
34. Swartz S, McSpadden JT. The Quantec rotary nickel titanium in-
strumentation system, Int J Epidemiol 2:14, 1999.
TEB SINA CHEHR
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92 Color Atlas of Endodontics
FIGURE 6-2 Left, Characteristic ultrasonic movement, showing
a longitudinal motion. Right, A file set at an angle to the driver has
a transverse oscillation with nodes (N) and antinodes (A).
FIGURE 6-3 Photomicrograph of an activated Mile (#20).
Sonic instruments (Figure 6-4) produce an elliptical
pattern of transverse oscillation when operated in air, a
pattern similar to those powered ultrasonically. How-
ever, this large transverse motion is eliminated entirely
and replaced by a true longitudinal vibration of the file
when the file is activated and loaded in the root canal
( Figure 6-5). 4 This longitudinal file motion may offer a
superior action within the root canal.
FIGURE 6-4 A sonic handpiece.
FIGURE 6-5 The oscillation pattern of a sonic instrument. The
i nitial transverse motion in air changes to a vertical action when
the file contacts the root canal wall.
FILE DESIGN
Different file designs are used with sonic and ultrasonic
i nstruments, and different manufacturers have unique
designs of files for use with endosonic instruments. The
Cavi-Endo (Dentsply, York, Pennsylvania) uses small
K-files (#15, #20, #25). Sonic instruments are supplied
with two file types: Rispisonic and Shaper (Micro-Mega,
Prodonta, Geneva, Switzerland) (Figure 6-6). These files
 Chapter Six Sonics and Ultrasonics in Endodontics
FIGURE 6-6 Files used in sonic instruments. From left to right
are displayed the Heliosonic file (Micro Mega Prodonta, Geneva,
Switzerland) (based on a triple file), the characteristic Shaper file,
and the Rispisonic file.
FIGURE 6-8
have spiral blades protruding along their lengths and
non-cutting tips. The Rispisonic spirals are closer to-
gether than.those of the Shaper file. In addition, the
Rispisonic file does not follow International Standards
Organization (ISO) standards and has a thicker cross-
section toward the coronal part of the file.
Although canals prepared with ultrasonics are
smooth, the cutting edges of the file produce character-
istic markings in a diagonal wave pattern on the canal
walls (Figure 6-7). This pattern is caused by the action
of the K-file flutes because the distance between the
crests produced in the dentine and the cutting edges is
similar.7
93
FIGURE 6-7 Photomicrograph showing the characteristic ridging
pattern made in the canal by a K-type file. (Courtesy Dr. K.V. Krell,
West Des Moines, Iowa.)
Cavitational activity.
CAVITATION AND ACOUSTIC
MICROSTREAMING
During operation of the endosonic file, water or an irrig-
ant such as sodium hypochlorite is passed over the oscil-
lating tip. Cavitation is generated by the movement of the
file within the water supply, and is claimed to be one of
the primary beneficial effects of the endosonic instru-
ment.8 Cavitation consists of the growth and subsequent
violent collapse of bubbles in fluid (Figure 6-8). This mo-
tion results in the development of a shock wave, increased
temperature and pressure, and free radical formation in
the fluid. Cavitational activity is readily demonstrated
within the cooling water supply of the ultrasonic scaler. 9
94 Color Atlas o f Endodontics

FIGURE 6-9 Acoustic streaming. FIGURE 6-10 Acoustic streaming around a sonic file helps clean
debris from around the file.

FIGURE 6-11 Streaming within an artificial root canal. Banding occurs where the red dye has
been moved in areas of intense streaming. (Courtesy Dr. K.V. Krell, West Des Moines, Iowa.)

Although transient cavitation may theoretically occur dur-
ing use of an endosonic instrument, sufficiently high
sound pressure fields are unlikely to occur around the os-
cillating file unless it is operated at high displacement am-
plitudes. 3 The more beneficial biophysical action of the
file is likely to result from acoustic microstreaming.
Acoustic streaming is produced around an object os-
cillating in a liquid. It is characterized by the production
of large shear forces that are capable of dislodging or
disassociating lumps of material (Figure 6-9). However,
the forces of acoustic streaming are not sufficient to
break up the bacterial cell wall.
The oscillating file in the endosonic system pro-
duces streaming fields along its length, with the great-
est shear stresses being generated around points of
maximum displacement such as the tip of the file and
the antinodes along its length. 3,10 These streaming
fields are likely to be responsible for many of the ben-
eficial effects attributed to the use of endosonics and
are important in moving the irrigant around the root
canal (Figure 6-10). However, the efficiency of such
forces depends on the amount of damping and file con-
straint that occurs when the instrument is working
within the canal. 3
Streaming forces occurring around the file disassoci-
ate clumps of bacteria without disruption." The acoustic
streaming generated by the file may play a useful role in
reducing the number of bacteria in the canal by remov-
 Chapter Six
FIGURE 6-12 Analytic (Sybron Dental Specialties, Orange, CA)
ultrasonic inserts. These inserts are for prosthetic post vibration;
use in the pulp chamber; and use in the suborifice, middle, and
apical third regions.
BOX 6-1
Ultrasonics in Nonsurgical Root Canal Preparation
Endosonics can shape curved canals, but overinstrumentation
can occur if it is used in the canal too long. Therefore the clini-
cian should keep in mind the following:
The files need to be pre-curved.
Small files (such as #15) should be used.
Ultrasonic files behave in a similar manner to hand instru-
ments, but transportation of the canals does occur:
It is less common in the apical region.
It is greatest in the middle portion of the canal.
Root canal debridement depends on the following:
. Oscillation of the file to oscillate
*Krell KV, Johnson R, Madison S: Irrigation patterns during ultrasonic canal instrumentation Part 1. K-type files, J Endod 14:65, 1988.
i ng the smear layer and debris harboring bacteria and
loosening aggregates of bacteria, thereby facilitating
their mechanical removal.
The main advantage of ultrasonic files is that they
move irrigant around the canal and penetrate to the
most apical extent of the instrument (Figure 6-11).1 2,13
The general conclusion is that acoustic microstream-
ing does occur around the oscillating file. To be effec-
tive in this action, the file must be kept moving at all
times so that free oscillation can be maintained. In-
Sonics and Ultrasonics in Endodontics 95
FIGURE 6-13 A selection of ultra-slim titanium tips (CPR Nos. 6,
7, 8) for use deep within root canals in challenging situations.
The choice of irrigant solution, sodium hypochlorite being
the preferred choice
The form of irrigation, with ultrasonic irrigation being supe-
rior to a needle and syringe*
Ultrasonic preparation produces cleaner canals because of
the following:
The synergistic relationship between the ultrasound and the
sodium hypochlorite
The increased temperature produced in the sodium
hypochlorite
struments are generally moved circumferentially within
the canal space. Box 6-1 provides a summary of the
way ultrasonics can be used in conventional root canal
treatment.
In addition to the use of endosonic files to clean and
shape the root canal, numerous additional applications
for ultrasonic activated instruments have been devel-
oped. Specifically, modified ultrasonic tips have been de-
veloped that play valuable roles in access refinement
( Figure 6-12), root canal retreatment (Figure 6-13), and
96 Color Atlas o f Endodontics

FIGURE 6-14 Examples of the original CT (Analytic, Sybron Dental Specialties, Orange, CA) ultra-
sonic tips that revolutionized apical root end cavity preparation.

FIGURE 6-15 KIS (Obtura Spartan, Fenton, MO) ultrasonic surgery tips. The increased length of-
fers improved visibility and cutting.

apical surgery (Figures 6-14 and 6-15). A variety of differ-
ent tip designs are available for these clinical tasks. 14 Gen-
erally these tips are used with ultrasonic drivers because
they have more power, but sonic drivers have been used as
well.
ACCESS REFINEMENT
Ultrasonic tips offer a precise method of dentine re-
moval and thereby facilitate canal location and identi-
fication. The narrow profile of these tips allows excel-
lent visualization compared with that of conventional
handpieces because no bulky head obstructs the path
of vision.
RETREATMENT
During root canal retreatment the operator needs to gain
access to the root canal system. The most important part
of the canal to be instrumented is the apical third, which
may present many obstructions that complicate the pro-
cedure. Metallic posts often obstruct access. Ultrasonic
energy is a useful tool in such cases to vibrate the post or
chip away at the surrounding cement.
Metallic objects such as silver points and fractured
instruments may also obstruct access to the apical third.
The clinician must take particular care when vibrating
silver points because the soft metal is easily abraded. Of-
ten silver points break into fragments, making retrieval
more difficult. This difficulty may be overcome by using
indirect ultrasonic vibration (e.g., grasping the point
with a pair of Steiglitz pliers and applying ultrasonic en-
ergy to the pliers).
Sectioned silver points in the apical third of roots can
be difficult to remove. Ultrasonic vibration can be used
to chip away any remaining cement and provide access
for a K-type and/or Hedstrom file to bypass the silver
point and aid in retrieval.
 Chapter Six Sonics and Ultrasonics in Endodontics
FRACTURED INSTRUMENT REMOVAL
Ultrasonic vibration may be used to facilitate fractured
instrument removal. The clinician must take care to as-
certain the type of metallic obstruction because nickel-
titanium (NiTi) and stainless steel respond differently to
ultrasonic vibration. Direct ultrasonic vibration causes
NiTi to fragment, so the clinician must work carefully
around the fragment. Stainless steel is more resistant to
vibration and responds to it by subsequently loosening.
Ultrasonic vibration is applied directly to stainless
steel files. Fine inserts can be used to work counter-
clockwise around broken instruments. This technique
often results in an "unscrewing" action that assists in
removal.
USE OF ULTRASOUND IN APICAL SURGERY
Ultrasound offers considerable advantages in apical
surgery. Rotary instrument heads are relatively bulky
compared with ultrasonic tips. Ultrasonic tips allow bet-
ter access and visibility because of their small size, and
the unique bends incorporated in their design permit
easy access to the root end. 15,16 The decreased size of ul-
trasonic tips enables small root-end preparations to be
made parallel to the long axis of the root.
SUMMARY
The two main advantages of ultrasonic systems are the
ultrasonically activated file and the action of irrigant
passing over it. Although the ultrasonic system provides
excellent irrigation, it depends on the proper technique
and clinicians must use it with care if maximum benefit
is to be obtained. Sodium hypochlorite is the irrigant of
choice. Evidence supports the importance of keeping the
file oscillating and moving freely within the canal.
Since the introduction of ultrasonics to endodontics,
the application of the technology has evolved and ex-
panded. The development of new instruments has led to
the use of ultrasonics in access modification, removal of
foreign objects, and apical surgery.
The introduction of piezoelectric ultrasonic units of-
fers the clinician a more compact and powerful device
compared with more traditional magneto strictive
units.17,18 Both types of ultrasonic units are more pow-
erful than sonic devices, which rely on air pressure to
produce oscillation of the instruments. Piezoelectric units
97
convert crystal deformation into mechanical oscillation,
whereas magnetostrictive units convert electromagnetic
energy into mechanical energy.'
Modern endodontic tools such as the operating mi-
croscope have allowed increased operative precision, and
ultrasonic instrumentation has an important place in the
armamentarium of the endodontic practitioner.
References
1. Richman RJ: The use of ultrasonics in root canal therapy and root
resection, J Dent Med 12:12, 1957.
2. Martin H: Ultrasonic disinfection of the root canal, Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 42:92, 1976.
3. Walmsley AD: Endosonics: ultrasound and root canal treatment:
the need for scientific evaluation, Int Endod J 20:105, 1987.
4. Walmsley AD, Williams AR: The effect of constraint on the oscil-
latory pattern of endosonic files, J Endod 15:189, 1989.
5. Lumley PJ, Walmsley AD: The effect of precurving on the perfor-
mance of endosonic K-files, J Endod 18:232, 1992.
6. Walmsley AD, Laird WRE, Lumley PJ: Ultrasound in dentistry: II.
Periodontology and endodontics, J Dent 20:11, 1992.
7. Briggs PEA et al: The dentine-removing characteristics of an ultra-
sonically energized K-file, Int Endod J 22:259, 1989.
8. Cunningham WT, Martin H, Forrest WR: Evaluation of root canal
debridement with the endosonic ultrasonic synergistic system, Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 53:401, 1982.
9. Walmsley AD, Laird WRE, Williams AR: Dental plaque removal
by cavitational activity during ultrasonic scaling, J Clin Periodon-
tol 15:539, 1988.
10. Ahmad M, Pitt Ford TR, Crum LA: Ultrasonic debridement of
root canals: acoustic streaming and its possible role, J Endod
13:490, 1987.
11. Ahmad M: Effect of ultrasonic instrumentation on Bacteroides in-
termedius, Endod Dent Traumatol 5:83, 1989.
12. Krell KV, Johnson R, Madison S: Irrigation patterns during ultra-
sonic canal instrumentation Part 1. K-type files, J Endod 14:65,
1988.
13. Druttman AC, Stock CJR: An in vitro comparison of ultrasonic
and conventional methods of irrigant replacement, Int Endod J
22:174, 1989.
14. Ruddle CJ: Micro-endodontic non-surgical retreatment, Dent Clin
Nortb Am 41:429, 1997.
15. Carr GB: Endodontics at the crossroads, J Calif Dent Assoc 24:20,
1996.
16. Carr GB: Ultrasonic root end preparation, Dent Clin Nortb Am
41:541, 1997.
17. Stamos DE et al: An in vitro comparison study to quantitate the
debridement ability of hand, sonic, and ultrasonic instrumenta-
tion, J Endod 13:434, 1987.
18. Archer R et al: An in vivo evaluation of the efficiency of ultra-
sound after step-back preparation in mandibular molars, J Endod
18:549, 1992.
TEB SINA CHEHR
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100 Color Atlas o f Endodontics
Since the early days of endodontic treatment, much
discussion has taken place regarding the ideal location
for the terminus of the root canal filling. This obsession
with the apical extent of the fill is undoubtedly a result of
the historical fact that dentists in the late nineteenth and
early twentieth centuries were hindered by an inadequate
armamentarium. Access openings were difficult because
only belt-driven, low-speed handpieces using burs that
dulled quickly were available. Files were likewise made
of inferior alloys that did not remain sharp, corroded,
fractured easily, and exhibited poor flexibility. Their
manufacturing also lacked consistency. Local anesthesia
was in its infancy and was infrequently employed. Pa-
tients were frequently uncomfortable and unwilling or
unable to tolerate the cleaning and shaping procedures
required to produce an ideal preparation. Therefore in-
strumentation was frequently discontinued when the
procedure became too uncomfortable for the patient or
when the dentist could instrument no further because of
his own discomfort or the limitations imposed by his ar-
mamentarium. These numerous constraints meant that
dentists had great difficulty reaching the apical portion
of the root canal, particularly in posterior teeth, much
less instrumenting it adequately. The only means early
operators had to evaluate their progress was to expose a
radiograph (the equipment for which was itself in its in-
fancy and not universally available) and see whether they
had succeeded in reaching the apex. If they were fortu-
nate enough to have overcome all the procedural obsta-
cles in their path and arrived at the root apex, filling
could begin.
As one might suspect, not all endodontic treatment
is successful. In an attempt to define important parame-
ters in determining success or failure, a large-scale inves-
tigation was undertaken in the 1960s at the University
of Washington. 9 The authors retrospectively observed ra-
diographs of more than 1000 cases for 5 years and at-
tempted to correlate their radiographic observations
with clinical signs of success or failure. In their judg-
ment, nearly 60% of the failures were caused by poor
obturation. A more accurate way of expressing the find-
ings would have been that more than 60% of the fail-
ures appeared radiographically to have been incom-
pletely obturated, because the study design was
incapable of demonstrating cause and effect. As a result
of this semantic error, the impression was inadvertently
created that obturation was more important than in-
strumentation, which is difficult to assess. In all proba-
bility, cases that were poorly obturated also exhibited in-
adequate cleaning and shaping.
Many prognosis studies have failed to emphasize the
i mportance of cleaning and shaping, the quality of which
is impossible to determine radiographically or clinically,
while concentrating on the length of the obturation,
which is more practical to measure. This resulted in nu-
merous pronouncements regarding the importance of the
exact length of the filling material in relation to the ra-
diographic apex. Great importance was placed on
whether a filling was "long" or "short." 10 . 11 This was
the norm until Schilder8 emphasized the fact that the ob-
j ectives of endodontic instrumentation are to remove all
organic debris (and bacteria) from the root canal and
then produce a shape that is conducive to the placement
of a three-dimensional root canal filling to fill the canal
and all its ramifications, preventing the recontamination
of the cleaned canal.
The earlier studies do, however, demonstrate that the
difference in success depends on where the root canal fill-
ing ends. Root canal fillings that are long (i.e., those that
extend beyond the radiographic apex) seem to be asso-
ciated with a decreased chance of success .12-14 Reasons
for these findings are numerous and complex. The most
favorable histologic responses to endodontic procedures
are associated with working lengths short of the apical
constriction regardless of the pulpal status (vital versus
necrotic). This is also true when bacteria are present in
the periapical tissues. Extrusion of sealer and/or core ma-
terial results in a severe inflammatory response and for-
eign body reaction despite the absence of pain. 13
First, a distinction must be made between the length
of the instrumentation and the length of the obturation.
Because the key to success is to eliminate bacteria from
the root canal system, instrumentation must be carried
throughout the length of the canal. When instrumenta-
tion was in its infancy, preparing the canal to receive
gutta-percha was difficult, so other materials were
sought that could be more easily introduced into a canal
that was often inadequately prepared. Solid core materi-
als such as silver points could be forced through residual
bacteria and debris to the apex or beyond, which meant
that despite the presence of obturating material in the
apical area, the area was neither cleaned nor shaped and
therefore the treatment was destined to fail.
A second distinction that must be made is between
"overfilling" and "overextension." If a root canal is
analogous to a pipe, then overfilling means that the pipe
is filled to capacity and that any additional material must
extrude from one end or the other (Figure 7-1). Overex-
tension, which describes the presence of filling material
in the per1radicular bone, does not necessarily result only
when the canal has reached maximum capacity (Figure
7-2). In the previous silver point example, a size 20 silver
point could be pushed through a size 100 canal to exit
through the apical foramen without approaching the di-
mension necessary to obturate the canal. Again, lack of
an apical seal may result in the periapical area being in-
fected by the contents of the root canal.
A third element that may portend success or failure is
the toxicity of the contents of the root canal and/or the
sealer used. One reason for overextension of a gutta
percha cone is poor adaptation. If the cone and the api-
cal preparation are the same size and shape, the conical
shape or resistance form should prevent overextension
even in teeth with apical resorption where an adequate
 Chapter Seven
FIGURE 7-1 Note the overextension of gutta-percha and lack of
adaptation to the canal walls.
FIGURE 7-2 A radiograph of a failing maxillary left lateral incisor
demonstrating an overextension.
stop cannot be prepared (Figure 7-3). Overextension,
then, may be indicative of a poor fit and a poor seal in
the apical area. Bacteria and their toxins could continue
to leak from the root canal, preventing apical healing.
Additionally, although gutta-percha itself is relatively in-
ert,15 sealers are not. Sealers, even when confined to the
root canal, are toxic and cause periapical inflammation
that can last for years. 16 Overextension of sealer into the
periodontal ligament and bone can preclude healing and
promote chronic inflammation.
Therefore the goals of nonsurgical root canal treat-
ment should be to clean the canal thoroughly, remove as
much bacteria and debris as possible, shape the canal
into a continuously tapering cone to accommodate the
Obturation 101
FIGURE 7-3 Diagram of two cones depicting the tapered canal and
point adaptation. The taper developed in preparing the canal provides
resistance form that prevents extrusion when the point is seated.
FIGURE 7-4 When the apical constriction has been lost because
of inaccurate length determination or resorption, a stop can be pre-
pared by deliberately creating a ledge within the canal space.
obturating material, and fill the space completely. The
obturating material should fill the canal, but it should
not extend beyond its confines. Respecting the apical
constriction and preparing a stop for the obturating ma-
terial is desirable when possible, but in many cases peri-
apical inflammation has already caused resorption of the
apex." In this case, several alternative methods can be
used to confine the material to the canal. Clinicians
should carefully determine the length of the tooth to the
apex, then step back 1 or 2 mm and deliberately create a
circumferential ledge by reaming the canal several sizes
larger. This technique can be used advantageously in
some canals, but can also fracture the thin apical end of
the root (Figure 7-4).
1 02 Color Atlas o f Endodontics
FIGURE 7-5 A radiograph of a maxillary right lateral incisor
demonstrating an accessory cone extending into the periradicular
tissues. This results when the master cone is not adapted circum-
ferentially in the apical third of the root.
In reality, if the canal and the gutta-percha points are
tapered, the point should enter the canal until it makes cir-
cumferential contact with the canal walls. The reason
points are overextended or accessory points slide past a
master cone that has stopped at the prepared length is that
the master cone is making only partial contact with the
canal walls (Figure 7-S). This problem can be circumvented
by using solvent to customize the apical end of the point
or by using a form of thermoplasticized gutta-percha.
Another method to prevent the overextension of
gutta-percha is to use an apical plug. The plug can be
formed of dentin removed from the canal walls; dentin
packed into the apical portion of the canal can prevent
extrusion. 18 . 19 The difficulty with dentin chips is that the
clinician can never be certain exactly what is being packed
into the apical portion of the canal-it seems to be a mix-
ture of dentin, canal contents, and potentially bacteria
and their by-products. This unknown mixture, if bacteri-
ally contaminated (teeth with infected, necrotic pulps fre-
quently exhibit apical resorption), can lead to non-healing
and chronic periapical inflammation . 2 0-22 A better choice
may be to mix a nearly solid mass of calcium hydroxide
and create a plug of that biocompatible material in the
apex of the tooth. 23 Recently mineral trioxide aggregate
( NITA) has become available and is a viable option .24
OBTURATING MATERIALS
Sealers
Regardless of the obturation technique employed, sealers
are an essential component of the process. Sealers fill the
space between the canal wall and core obturation mate-
rial and may fill lateral and accessory canals, isthmuses,
and irregularities in the root canal system. The ideal
properties of an endodontic sealer were outlined by
Grossman 25 and are provided in Box 7-1.
The most popular sealers are grouped by type: zinc
oxide-eugenol formulations, calcium hydroxide sealers,
glass ionomers, and resins. Regardless of the sealer se-
lected, all are toxic until they set. For this reason, extru-
sion of sealers into the periradicular tissues should be
avoided. 13
Zinc oxide-eugenol and resin sealers have a history
of successful use over an extended period. Zinc
oxide-eugenol sealers have the advantage of being re-
sorbed if extruded into the periradicular tissues . 26 Cal-
cium hydroxide sealers were recently introduced for their
potential therapeutic benefits. In theory these sealers ex-
hibit an antimicrobial effect and have osteogenic poten-
tial. Unfortunately these actions have not been demon-
strated, and the solubility required for release of calcium
hydroxide and sustained activity is a distinct disadvan-
tage. Glass ionomers have been advocated for use in seal-
ing the radicular space because of their dentin bonding
properties. A disadvantage is their difficult removal if re-
treatment is required.
Sealers containing paraformaldehyde are contraindi-
cated in endodontic treatment. Although the lead and
mercury components have been removed from the for-
mulations over time, the paraformaldehyde content has
remained constant and toxic. These sealers are not ap-
proved by the U. S. Food and Drug Administration. 27
Controversy surrounds removal of the smear layer
before obturation. The smear layer is created on the
 Cbapter Seven
canal walls by manipulation of the files during cleaning
and shaping procedures. It is composed of inorganic and
organic components that may contain bacteria and their
by-products. In theory remnants left on the canal wall
may serve as irritants or substrates for bacterial growth
or interfere with the development of a seal during obtu-
ration. Although fluid movement may occur in obturated
canals, bacterial movement does not appear to take
place. 28 Recent evidence suggests that removal of the
smear layer can enhance penetration of the sealer into
the dentinal tubules. 29,30
Removal of the smear layer can be accomplished af-
ter cleaning and shaping by irrigation with 17% ethyl-
enediaminetetraacetic acid (EDTA) for 1 minute. Irriga
tion should be followed with a final rinse of sodium
hypochlorite.
The radiopacity of sealers can be increased by adding
opacifiers such as barium sulfate or silver particles. Al-
though these opacifiers can produce an esthetically pleas-
ing result, claims of superiority of obturation based on
radiographic appearance are inaccurate. The increased
radiopacity may mask voids or imperfections in the com-
paction and is unrelated to the quality of seal obtained.
In addition, sealers with silver particles may stain the
tooth structure if they are left in the pulp chamber.
Acceptable methods of placing the sealer in the canal
include the following31:
• Placing the sealer on the master cone and pump-
ing the cone up and down in the canal
• Placing the sealer on a file and spinning it counter-
clockwise
• Placing the sealer with a lentulo spiral
• Using a syringe
• Activating an ultrasonic instrument
The clinician should use care when placing sealer in a
canal with an open apex to avoid extrusion.
Core Obturation Materials
The ideal properties of an obturation material as out-
lined by Grossman25 are listed in Box 7-2.
Historically, a variety of materials have been em-
ployed to obturate the root canal, falling into three
broad categories: solids, semisolids, and pastes. In the
early days of endodontics, because of the limitations of
their equipment dentists found preparing canals to the
size and shape necessary for the introduction of gutta-
percha points very difficult. In the 1940s, Jasper 32 intro-
duced cones made of silver, which he claimed produced
the same success rate as gutta-percha but were easier to
use. Silver cones met many of the criteria for filling ma-
terials but suffered from several deficiencies. The rigidity
that made them easy to introduce into the canal also
made them impossible to adapt to the inevitably irregu-
lar canal preparation, encouraging leakage. When leak-
age occurred and the points contacted tissue fluids, they
corroded, further increasing leakage 33 ( Figure 7-6). The
Obturation 1 03
FIGURE 7-6 A mandibular left second molar treated with silver
cones. Failure has occurred despite placement to the correct
l ength.
BOX 7-2
Ideal Properties o f an Obturation Material
1. It should be easily manipulated and provide ample
working time.
2. It should be dimensionally stable and not shrink or
change form after it is inserted.
3. It should seal the canal laterally and apically, conform-
i ng to its complex internal anatomy.
4. It should not irritate the periapical tissues.
5. It should be impervious to moisture and nonporous.
6. It should be unaffected by tissue fluids and not corrode
or oxidize.
7. It should not support bacterial growth.
8. It should be radiopaque and easily discernible on ra-
diographs.
9. I t should not discolor tooth structure.
10. It should be sterile.
11. It should be easily removed from the canal if necessary.
corrosion products themselves were cytotoxic, 34 which
i mpeded periapical healing.
At the opposite end of the rigidity spectrum are the
pastes. Pastes also fulfill many of the criteria listed pre-
viously and can easily adapt to the most complex
internal anatomy. However, their extreme flowabil-
ity can be a negative factor, and overextension or un-
derextension is a frequent result of using a paste tech-
nique. 35 The movement of the material occurs along
the path of least resistance; pressure is required for
the material to flow laterally to fill the anatomic vari-
ations of the canal. If less pressure is required to flow
through the apex than to flow laterally, the mater-
ial will flow through the apex. Unfortunately, the op-
erator has no way of knowing where the material is
1 04 Color Atlas of Endodontics

FIGURE 7-7 A mandibular left second molar treated with a Sargenti formulation paste. Note the
unfilled mesial canals and the extrusion of material into the mandibular canal, which resulted in
paresthesia.

A B

FIGURE 7-8 A, A treated mandibular left second molar exhibiting mesial bone loss. B, On flap re-
flection a vertical root fracture was detected.

flowing except by exposing a radiograph. By the time
the radiograph develops, retrieval of overextended ma-
terial becomes a surgical matter. Additionally, pastes
have been associated with the addition of undesirable
and toxic chemicals such as paraformaldehyde, which
can produce irreversible tissue damage when extended
beyond the confines of the root canal system (Figure
7) . 36,37
Currently gutta-percha, a semisolid material, is the
most widely used and accepted obturating material. 38
Chemically, gutta-percha is the trans isomer of polyiso-
prene, a naturally occurring relative of rubber. In the
production of dental obturating cones, approximately
20% gutta-percha is combined with approximately
65% zinc oxide, 10% radiopacifiers, and 5% plasticiz-
ers. Clearly, what clinicians refer to as gutta-percha is
really a compound composed primarily of other sub-
stances. Unlike rubber, gutta-percha cannot be com-
pressed by pressure, being less compressible than water,
which is considered incompressible. 3 9 Excessive con-
densation pressure cannot cause flow of gutta-percha
and does not improve the seal of a root canal fill 4 0 but
can fracture roots (Figure 7-8). Gutta-percha can be
made to flow if it is modified by either heat or solvents.
Gutta-percha exists in two distinctly different crystalline
phases, which Bunn termed "alpha" and "beta" modi-
fications. 41 The naturally occurring form is the alpha
form, which melts when heated above 65° C. If it is
cooled extremely slowly, the alpha form will recrystal-
lize. If it is cooled routinely, the beta form recrystallizes,
which is the form in which most gutta-percha exists. Al-
though the mechanical properties of the two forms are
the same, when alpha phase gutta-percha is heated and
cooled, it undergoes less shrinkage than the beta form,
making it more dimensionally stable for use with ther-
moplasticized techniques.
In addition to its ability to conform to canal irregu-
larities, gutta-percha exhibits very low toxicity, being es-
 Chapter Seven
FIGURE 7-9 Gutta-percha is relatively inert in periradicular con-
nective tissues.
FIGURE 7-10 Nonstandardized (top) and standardized (bot-
tom) cones.
sentially inert when in contact with the periapical tissues
( Figure 7-9).42,43 Additionally, it is easily removed if post
space is needed or if retreatment becomes necessary.
Gutta-percha does not adhere to the canal walls even
when thermoplasticized and still requires a sealer to pre-
vent leakage. 44,45
Gutta-percha cones are available in two forms: non-
standardized and standardized (Figure 7-10). The non-
standardized cones have relatively small diameter tips com-
pared with their larger bodies. Their nomenclature refers
to these two dimensions-a "fine-medium" cone has a fine
tip and a medium body. Standardized cones are designed
with an overall 0.02 mm / mm taper, to match the taper of
endodontic files. Recently, as files of various tapers have
been introduced, different tapers of gutta-percha cones are
now being manufactured (Figure 7-11).
TECHNIQUES
Clinicians should be able to use a variety of obturation
techniques because each case is unique and may require
Obturation 1 05
FIGURE 7-11 A .20 series GT file and a .04 gutta-percha cone.
FIGURE 7-12 A, Master cone in place with finger spreader.
B, Accessory cone placed in space created by the finger spreader.
C, Accessory cones in place, completing the obturation process.
modification of routine procedures for an optimal result.
The following are common obturation techniques cur-
rently within the standard of care.
Lateral Condensation
Lateral condensation is the most common technique for
obturating the root canal space. This technique can be
used in most clinical situations and can be modified to
facilitate unusual cases. Before performing obturation
with lateral condensation, the clinician prepares the root
canal in a continuously tapering manner to an endpoint
that ideally coincides with the minor constriction ,46 often
referred to as the working length. A standardized point
(the "master cone") is selected with a diameter that is
consistent with the largest file used in the canal at the
working length (Figure 7-12).
The clinician grasps the master cone with forceps at
the point where the distance from the forceps to the tip
is equal to the working length and inserts it into the
canal. If the fit is correct, the point will exhibit "tug-
back," or resistance to removal at working length. A
1 06 Color Atlas o f Endodontics
FIGURE 7-13 An ovoid distal canal of a mandibular molar with
a master cone in place.
radiograph is exposed to verify that the point is correctly
positioned in the canal. The cone is then removed,
coated with sealer, and reinserted.
Nonstandard points are used to obliterate the re-
maining space. A spreader is selected that matches the
length of the canal and the taper of the points. Finger
spreaders provide better tactile sensation and are less
likely to induce fractures in the root than the more tra-
ditional D-1 1T spreader . 47 Nickel-titanium spreaders
provide increased flexibility, reduce stress, and penetrate
deeper compared with stainless steel instruments. 41,41
The spreader is introduced into the canal to a depth that
approaches within 1 mm of the working lengths° and ro-
tated to create a space lateral to the master cone for
placement of an accessory cone. The process is repeated,
with the cones being condensed until the spreader can
no longer penetrate the mass. Only light pressure is re-
quired because the gutta-percha is not compressible and
because as little as 1.5 kg of pressure is capable of frac-
turing the root.51 The excess gutta-percha in the chamber
is then seared off and lightly vertically condensed with a
heated plugger approximately 1 mm below the orifices
to the canals or the cementoenamel junction in anterior
teeth.
Apical Modification with Solvent
A disadvantage to lateral condensation of gutta-percha is
that the material does not conform to the irregularities of
the canal. Although lateral condensation reduces the
space between the obturating cones, unfilled areas
( "voids") remain as potential paths for leakage.52 Be-
cause the preparation of a completely round canal is im-
possible and because the crucial apical area of the canal
is likely to contain lateral canals, the tug-back experi-
enced and the image displayed on a two-dimensional ra-
diograph may give a misleading impression of a dense
FIGURE 7-14 Adaptation of the master cone can be accom-
plished by softening the point in a solvent such as chloroform.
fill. In reality only point contact may exist between the
core and the walls of the canal (Figure 7-13). This situa-
tion is often discovered when an accessory point extends
i nto the periapical area despite a seemingly well-placed
master cone (see Figure 7-5).
To overcome this shortcoming, the clinician can tem-
porarily soften the tip of the point by dipping the mas-
ter cone in a solvent (chloroform, halothane, or euca-
lyptol) for several seconds and placing the softened
point in the canal (Figure 7-14). This produces an im-
pression of the apical portion of the canal in the mate-
rial. The clinician then removes the cone from the canal
for a few moments to allow the solvent to evaporate,
applies the sealer, and replaces it so that it is oriented in
the same direction as when the impression was made. 53
Although concerns have been raised about the use of
chloroform in the dental operatory, evidence indicates
that it is safe to use the material for fabricating custom
cones and for retreatment.14,55
Although standardized cones are available from size
15 (0.15 mm) to 140 (1.40 mm), occasionally a canal is
encountered that exceeds these dimensions. In such cases
a customized gutta-percha point can be created by
rolling several warmed gutta-percha points together with
a cement spatula on a glass slab. The point is cooled
with water and the size is tested in the canal and re-
rolled until an approximate fit is achieved. Solvent dip
may then be used to further adapt it to the walls of the
canal. Sealer and accessory points can then be used as
previously described (Figure 7-15).
Warm Lateral Condensation
Warm lateral condensation is a variant of traditional lat-
eral condensation. A heated instrument is introduced into
a tooth already obturated by lateral condensation to
soften the gutta-percha mass and enhance adaptation to
 Cbapter Seven
A
C gutta-percha removed. The Endotec instrument is then ac-
FIGURE 7-15 A, A master cone fabricated by rolling several
gutta-percha cones together on a glass slab. B, A standardized
cone compared with the fabricated cone. C, Obturation of a large
canal in a maxillary right central incisor using a rolled gutta-percha
cone.
the internal anatomy of the canal. This technique is use-
ful to increase the adaptation and density of teeth
obturated with lateral condensation, but it is especially in-
dicated for teeth with internal resorptive defects and
C-shaped canals. Liewehr et a156 demonstrated a nearly
15 % increase in weight after the use of the Endotec (Lone
Star Technologies, Westport, CT) device (Figure 7-16).
The Endotec is a battery-powered spreader, the tip of
which heats to approximately 350° C when activated.
One technique, called the "zap-and-tap" technique ,57 was
devised to avoid the problems caused when accessory
Obturation 1 07
FIGURE 7-16 An Endotec instrument used for warm lateral
condensation.
FIGURE 7-17 Obturation of a mandibular premolar with inter-
nal resorption using the zap-and-tap technique.
points placed during warm lateral condensation are
heated and subsequently removed en masse when the En-
dotec spreader is withdrawn. In the zap-and-tap technique
the canal is filled by lateral condensation and the excess
tivated (the "zap") for 4 to 5 seconds and moved in short,
continuous motions in and out of the gutta-percha mass.
As the gutta-percha becomes warm, the tip of the Endotec
instrument sinks further into the mass with each succes-
sive tap. When continued tapping fails to cause the tip to
penetrate further or when the tip is within 2 mm of the
working length, a cold spreader is introduced and rotated
to condense the thermoplasticized gutta-percha into the
canal anatomy. Accessory points coated with sealer are
then added until the canal is completely obturated (Fig-
ure 7-17). The same technique can be used with the Touch
`N Heat (Kerr Division, Sybron Digital Specialties, Inc.,
Orange, CA) instrument or with the System B (Analytic
Endodontics, Sybron Dental Specialties, Inc., Orange, CA)
instrument using Touch `N Heat tips.-5 8 Alternatively, an
ultrasonically activated spreader may be used. 59
Warm lateral condensation has many advantages.
Since it follows cold lateral condensation, heat is not in-
troduced to the apex of the tooth. The technique also al-
lows precise length control in the placement of the gutta-
percha and permits filling of voids, isthmuses, C-shaped
canals, lateral and accessory canals, and internal resorp-
tive areas. The potential for root fracture is reduced be-
cause the thermoplasticized gutta-percha mass flows eas-
ily into the anatomic variations with light spreader
pressure. It is an easy technique to learn and requires only
a relatively inexpensive addition to the armamentarium.
Warm lateral condensation does not require preheating
1 08 Color Atlas o f Endodontics
or special gutta-percha. In addition, cleaning and steril-
ization procedures are not complex.
Warm Vertical Condensation
In 1967, Schilder8 advocated vertical condensation with
warm gutta-percha as an alternative technique to cold
lateral condensation or silver points. He recognized the
i mportance of three-dimensional obturation of the entire
root canal system and was concerned about the potential
for voids and incomplete obturation occurring with
other techniques. 52 The principal advantage of warm
vertical condensation is its ability to adapt the warmed
and softened gutta-percha to irregularities and accessory
and lateral canals within the root canal system. 6 o,61
Warm vertical condensation relies on the placement
of a gutta-percha point, the removal of all but the apical
portion of the cone with heat, and the addition of small
segments that are heat-softened with a spreader and
compacted vertically with a plugger. This produces a ho-
mogeneous mass throughout the root canal. Further-
more, because the hydraulic pressure forces gutta-percha
and sealer into anatomic variations, the technique is
noted for its demonstration of lateral and accessory
canals radiographically.
The armamentarium needed consists of spreaders
and pluggers. The spreaders are not used to condense the
cold gutta-percha cones together, but rather serve as heat
carriers to soften the gutta-percha mass before conden-
sation with the cold plugger. The pluggers come in a va-
riety of sizes (8 [0.4 mm], 8 1/2 [0.5 mm], 9, 9'/, 10, 10 1/2
11, 11'/, 12) of increasing diameter and are marked at
5-mm intervals (Figure 7-18). After the root canal is
ready for obturation, prefitted pluggers are selected that
will enter the canal and descend to the desired depth.
The clinician can mark the length by placing rubber
stoppers on the cylindrical shaft of the instrument.
Marking the pluggers in this manner allows the clinician
to apply force to the gutta-percha mass while limiting
the force applied to the canal walls.
A nonstandard gutta-percha point is selected and its
tip cut away until it fits with tug-back approximately 2
or 3 mm short of the working length. The point is then
coated with sealer and used to place and distribute sealer
within the radicular space. A flame-heated red-hot car-
rier (spreader) is used to sear off the point at the orifice
of the canal. Heavy vertical pressure is immediately ap-
plied with the largest cold plugger to force the cone api-
cally. Because only the coronal 3 to 4 mm has been
heated, the spreader is again heated and carried 3 to 4
mm further into the gutta-percha mass, followed by
strong vertical condensation with the appropriate size
plugger. This process softens and removes much of the
gutta-percha, forcing it laterally and vertically into the
irregularities of the canal. The procedure is repeated un-
til the center of the canal is essentially empty except for
the apical 5 mm. The clinician then refills the canal by
touching the surface of the apical mass with the heat car-
FIGURE 7-18 Schilder (Dentsply Maillefer, Ballaigues, Switzer-
l and) pluggers used for warm vertical condensation. These instru-
ments are manufactured from size 8 to size 12 with half sizes.
rier, placing a warmed 2- to 4-mm segment of gutta-
percha in the canal, and condensing it vertically, repeat-
ing this process until the canal is filled (Figure 7-19).
Although the classic vertical condensation technique
is capable of producing a dense, homogeneous root canal
filling, there are several disadvantages. The technique is
difficult to master and time consuming. It is particularly
difficult to use in curved canals where the straight, rigid
pluggers are unable to penetrate to the necessary depth.
To allow the rigid carriers to contact the gutta-percha
within 4 or 5 mm of the apex, the canals must be pre-
pared larger and more tapered than in the lateral con-
densation technique, requiring the removal of additional
dentin, which weakens the root. In addition, enormous
pressures are created in the apical portion of the root,
producing more fractures than lateral condensation . 62
Because of these limitations, modifications to the
technique have been suggested. One two-step technique
consists of placing the sealer-coated initial gutta-percha
point, then using a small spoon-shaped curette heated
red hot to remove the coronal portion 8 to 10 mm in-
side the canal in anterior teeth. The portion of the point
that was removed is set aside. A heat carrier is used to
heat the apical portion, followed by heavy condensation
with a plugger as before. The superficial part of the coro-
nal apical gutta-percha mass is heated, and the reserved
portion is warmed, reinserted into the canal, and con-
densed to fill the remainder of the canal. This simplified
technique saves time but does not reduce the condensa-
tion pressures and may actually increase them.
A recent modification advocated by Ruddle 63 em-
ploys a similar technique for the placement and removal
of the gutta-percha point, a process he terms "down
packing." With this technique a thermostatically con-
trolled heat source, the Touch `N Heat instrument (Fig-
ure 7-20), is used instead of flame-heated spreaders. The
 Chapter Seven Obturation 1 09

FIGURE 7-19 Diagram of the warm vertical condensation technique. A, After a heated spreader
i s used to remove the coronal segment of the master cone, a cold plugger is used to apply vertical
pressure to the softened master cone. B, Obturation of the coronal portion of the canal is accom-
plished by adding a gutta-percha segment. C, A heated spreader is used to soften the material.
D, A cold plugger is then used to apply pressure to the softened gutta-percha.

FIGURE 7-20 The Touch `N Heat is used in warm gutta-percha techniques. (Courtesy Sybron, Inc.
Orange, CA.)
11 0 Color Atlas of Endodontics
second phase, refilling of the canal, is accomplished us-
ing the Obtura (Obtura Corporation, Fenton, Mary-
land) instrument, which is an electrically heated gutta-
percha "gun" that heats gutta-percha to a flowable
consistency and then expresses it into the canal through
a 23-gauge needle. The canal is filled by injection and
condensation of 4- or 5-mm segments. This step is re-
ferred to as "back-packing." The technique is somewhat
faster and because it uses uniformly softened gutta-
percha from the Obtura gun (Figure 7-21), it requires
less pressure than the standard technique. Unfortunately,
the down-packing portion produces the same pressures
in the apical end as the Schilder technique, and because
the same pluggers are used, identical amounts of tooth
structure must be sacrificed for their introduction. Ad-
ditionally, the technique is difficult to master and re-
quires a considerable armamentarium to employ.
Continuous Wave Obturation
Buchanan recently introduced the continuous wave of
condensation technique as a modification of the warm
vertical compaction technique for canal obturation. This
technique requires a smooth tapering funnel, an apical
constriction, and appropriate master cone adaptation.
The technique is often employed after cleaning and shap-
ing procedures using nickel-titanium rotary files. GT
FIGURE 7-21 The Obtura is used for thermoplastic injection
techniques and back-filling procedures with other techniques.
( Dentsply, Tulsa Dental, Tulsa, OK) gutta-percha points
are now manufactured to mimic the dimensions of the
GT files. The System B heat source is an electric device
that supplies heat to a plugger on demand (Figure 7-22).
Pluggers are available in standardized sizes, as well as
nonstandardized sizes that match conventional gutta-
percha cones. Cones and pluggers that match files of
greater taper are also available (see Figures 7-11 and
7-23). Several hand pluggers are available.
Heat is applied using the System B heat source at the
prescribed temperature (200° C) for a period of time de-
termined by the operator. Applying a constant source of
heat to a prefitted gutta-percha cone softens the gutta-
percha so the clinician can apply hydraulic pressure in
one continuous motion. As the plugger moves apically
the cone adaptation is more precise and the hydraulic
pressure increases, forcing the gutta-percha into canal ir-
regularities and accessory canals.
With the continuous wave technique a master cone
is adjusted to fit at the corrected working length and cut
back 0.5 mm. The largest plugger that will go to a depth
5 to 7 mm from the apex is selected, and the reference
point is marked with a stop. The master cone is coated
with sealer and used to coat the canal walls. The System
B heat source is set to 200° C and placed in touch mode.
The master cone is severed at the canal orifice and re-
FIGURE 7-22 The System B unit.
FIGURE 7-23 A System B plugger and a nonstandardized gutta-
percha point.
 Chapter Seven Obturation 111

moved. The clinician then places the cold plugger in the
orifice with firm pressure and activates the heat source.
The plugger is moved apically over a 1- to 2-second pe-
riod until it is 3 mm short of the binding point. Care
must be taken to ensure that the heat is never activated
for more that 4 seconds. Pressure is maintained on the
apical gutta-percha while the heat source is shut off for
5 to 10 seconds. After the gutta-percha has set the heat
source is activated for 1 second to separate the plugger
from the apical mass so the instrument can be removed.
A hand plugger with a tip diameter of 0.4 mm is used to
ensure the gutta-percha is not displaced and has set.
If no post space is required, a single cone backfill can
be accomplished by placing a sealer-coated gutta-percha
cone trimmed to a 0.5-mm tip diameter in the space va
cated by the plugger. This cone is seared off at the orifice,
and a final sustained pressure completes the condensa-
tion. An alternative method is back-filling with injectable
thermoplasticized gutta-percha (Obtura).
As with all procedures, continuous wave obturation
has inherent risks. The use of thermoplasticized gutta-
percha techniques creates a potential for extrusion of
materials into the periodontal structures as well as dam-
age to the periodontal ligament and supporting alveolar
bone from heat. An increase of 10° C above body tem-
perature appears to be a critical threshold for injuring
osseous tissues. 64 Evidence suggests that the use of flame-
heated carriers poses a greater risk of injuring the peri-
odontal structures. 65,66 Carriers heated in this manner
can reach temperatures of 342° to 380° C.67,68 The in-
j ectable gutta-percha technique 69 and the continuous
wave condensation technique 66,70 appear to produce
temperature changes below the critical threshold when
used at the recommended temperatures.
walls. The gutta-percha is preheated, and the needle is
placed in the canal within 3 to 5 mm of the apical ter-
minus. Gutta-percha is then gradually, passively injected
by squeezing the trigger of the gun. The needle backs out
of the canal as it is filled. The gutta-percha is then gently
compacted with pluggers that have been dipped in alco-
hol to prevent the plugger from sticking to the softened
gutta-percha. Alternatively, the clinician may use a seg-
mental technique, in which 3- to 4-mm segments of
gutta-percha are sequentially injected and condensed. In
either case, condensation should continue until the gutta-
percha cools and solidifies, which takes 3 to 5 minutes.
This compensates for the contraction that takes place
when it cools.
The difficulty with this system is the same as that
of the other warm gutta-percha techniques and paste
systems-lack of control. Both overextension and un-
derextension are common findings (Figure 7-24). To
overcome this drawback, the clinician may use a hybrid
technique, beginning obturation using the lateral con-
densation technique. When the master cone and several
accessory cones have been placed so that the mass is

Injection o f Thermoplasticized
Gutta-Percha
Instead of introducing gutta-percha into the root canal
and applying heat to cause it to flow, the material can be
heated outside the tooth and injected in a thermoplasti-
cized state. The previously mentioned Obtura system
( see Figure 7-21) consists of a handheld gun that con-
tains a chamber surrounded by a heating element into
which pellets of gutta-percha are loaded and heated. Sil-
ver needles are attached to deliver the thermoplasticized
material to the canal. The gun is connected by a cord to
a control unit that allows the operator to adjust the tem-
perature and therefore the viscosity of the gutta-percha.
To use the system, the clinician prepares the canal in the
same manner as for lateral condensation. Because the
needles are small and the thermoplasticized material FIGURE 7-24 A, Preoperative radiograph of a mandibular left
flows readily, the clinician should not create too much first molar exhibiting internal resorption in the distal root. B, Obtu-
flare in the preparation. The apical terminus must re- ration with thermoplasticized gutta-percha reveals obliteration of
main as small as possible to prevent extrusion. After the resorptive space and extrusion of material into the periradicu-
preparing and drying the canal, the clinician loads the lar tissues, a potential complication of any of the warm gutta-
last file used with sealer and uses it to coat the canal percha techniques.
11 2 Color Atlas o f Endodontics
firmly lodged in the apical portion of the canal, a hot
plugger is introduced, searing the points off approxi-
mately 4 to 5 mm from the apex. Light vertical conden-
sation is applied to restore the integrity of the apical plug
of gutta-percha, and no attempt is made to warm it. The
remainder of the canal is then filled with thermoplasti-
cized gutta-percha as described previously. This tech-
nique is similar to Ruddle's but avoids the down-packing
step, which is time consuming, requires additional
widening of the canal, and creates potentially fracture-
producing apical pressure.
Carrier-Based Gutta-Percha
Originally the gutta-percha carrier systems (Thermafil,
Dentsply, Tulsa Dental, Tulsa, OK) were manufactured
with a metal core to which the manufacturer applied a
coating of gutta-percha. When heated over an open
flame, the gutta-percha would soften and could then be
introduced into the root canal. The technique became
FIGURE 7-25 The Thermafil oven with a Thermafil obturator.
FIGURE 7-26 AThermafil obturator and appropriate size verifier.
popular because the central core provided a rigid mech-
anism to facilitate placement of the obturation material.
This ease of placement often resulted in incomplete
cleaning and shaping and an attendant decrease in prog-
nosis. As with other obturation techniques, the quality
of cleaning and shaping dictates success. In addition, the
metallic core made placement of a post challenging.
Current advances in the carrier systems include the
development of a plastic core coated with alpha-phase
gutta-percha and a heating device that heats the carrier
and controls the temperature (Figure 7-25). Thermafil
offers another alternative to obturation with heated
gutta-percha 71 ( Figure 7-26). Recently Dentsply/Tulsa
Dental (Tulsa, OK) introduced GT obturators designed
to correspond to the sizes of the GT Profile nickel-
titanium rotary files (Figure 7-27). Having obturators
that are manufactured to correlate with the precise size
of the prepared canal may enhance the quality of obtu-
ration. The traditional Thermafil obturators are manu-
FIGURE 7-27 A size 50/.12 GT nickel-titanium file and the cor-
responding GT obturator.
 Chapter Seven
factured consistent with International Standards Orga-
nization file sizes but may not adapt to the coronal posi-
tion of the canal, which exhibits greater taper after
preparation with Gates Glidden drills.
The carrier-based technique requires the use of a
sealer, and the removal of the smear layer is recom-
mended 72 Grossman formulation sealers or resin sealers
consistent with AH26 are acceptable. Tubliseal and
Wach's Paste are not recommended. Size verifiers for the
gutta-percha carriers are available for selecting the size
of the obturator necessary for placement. The verifier
should fit passively at the corrected working length.
When the GT obturators are used the size should corre-
late with the shaping objective file.
After drying the canal and placing a light coat of
sealer, the clinician marks a carrier with a rubber stop
set at the predetermined length. This must be accom
plished using the millimeter calibration markings on the
carrier shaft. Markings are made at 18, 19, 20, 22, 24,
27, and 29 mm. A Bard-Parker blade can be used to re-
move gutta-percha on the shaft that may be obscuring
the calibration rings. After the rubber stop is set, the car-
rier is disinfected with 5.25% sodium hypochlorite for
1 minute and rinsed in 70% alcohol. 73
The carrier is then placed in the heating device. After
it is heated to the appropriate temperature, the operator
has approximately 10 seconds to retrieve the carrier and
insert it into the canal. This is accomplished without ro-
tation or twisting. The position of the obturation mate-
rial is verified radiographically. After waiting 2 to 4 min-
utes for the material to set, the clinician can section the
carrier several millimeters above the canal orifice. This
is accomplished by applying stabilizing pressure to the
carrier and cutting the device with an inverted cone,
round bur, or specially designed Prepi bur. Heated in-
struments are not recommended for this process because
they may result in displacement of the obturator. Vertical
compaction of the coronal gutta-percha can be accom-
plished and when necessary gutta-percha can be added,
heat softened, and condensed. A lubricant should be ap-
plied to the plugger to prevent adhesion and possible
displacement.
If post space is required for restoration of the tooth,
specially designed ProPost (Dentsply, Tulsa Dental,
Tulsa, OK) drills are recommended. The unique eccentric
cutting tip keeps the instrument centered in the canal
while friction softens and removes the gutta-percha and
plastic carrier. Evidence suggests that the seal is not al-
tered if this procedure is accomplished immediately. 74,75
If retreatment is required the plastic carrier has a
groove along its length to provide an access point for
placement of a file. Rotary .04 and .06 nickel-titanium
files may facilitate complete removal of the obturation
materials. When necessary, chloroform and hand files
can be used to remove the gutta-percha surrounding the
carrier.
Obturation 11 3
The plastic carriers are composed of two materials.
Sizes up to 40 are manufactured from a liquid crystal
plastic. Sizes 40 to 90 are composed of polysulfone poly-
mer. Both have similar physical characteristics, with the
polysulfone carriers being susceptible to dissolution in
chloroform.
THE CORONAL SEAL
Regardless of the technique used to obturate the canals,
coronal microleakage can occur through seemingly well-
obturated canals within a short time, potentially causing
infection of the periapical area.7,7 6-79 A method to protect
the canals in case of failure of the coronal restoration is
to cover the floor of the pulp chamber with a lining of
glass ionomer cement after the excess gutta-percha and
sealer have been cleaned from the canal. Glass ionomers
have the intrinsic ability to bond to the dentin, so they
do not require a pretreatment step. The resin-modified
glass ionomer cement is simply flowed approximately 1
mm thick over the floor of the pulp chamber and poly-
merized with a curing light for 30 seconds. Investigators
found that this procedure resulted in none of the exper-
i mental canals showing leakage. 79
WHEN TO OBTURATE
In patients who are asymptomatic, obturation may be
completed during the instrumentation appointment. In
general, teeth exhibiting vital pulp tissue and normal
periradicular structures are the best candidates for obtu-
ration at the instrumentation visit. Although there ap-
pears to be no difference in postoperative pain after
single-visit endodontic treatment of teeth exhibiting pulp
necrosis,$° teeth exhibiting necrotic pulps as well as those
exhibiting chronic apical periodontitis and chronic apical
abscesses resulting from pulp necrosis may be best man-
aged in two treatment visits. Recent clinical studies 8 l -83
indicate an improved prognosis for these cases if calcium
hydroxide is placed as an intracanal medicament and ob-
turation delayed until a second visit. 84 The calcium hy-
droxide serves as an antimicrobial dressing, reducing the
bacteria present in the radicular space, as well as a tem-
porary obturant.
Contraindications to single-appointment root canal
treatment include the following:
1. Significant pain and/or swelling
2. Inability to dry the canal
3. Persistence of purulent drainage in the canal dur-
i ng instrumentation
Two additional considerations are esthetics and the
ability to provide an adequate provisional restoration to
prevent coronal leakage between visits. The clinician
may need to obturate a tooth to facilitate placement of
an esthetic temporary crown in the anterior region.
11 4 Color Atlas o f Endodontics
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TEB SINA CHEHR
(4070932 - 6418770)
11 8 Color Atlas o f Endodontics

Successful retreatment depends on accurate diagnosis and Endodontic Considerations

identification of the etiology of failure. The clinician be-
gins by recording the patient's chief complaint and perti-
nent history. The causes of failure can almost always be
found by looking for a source of microorganisms and nu-
trients (persistent or recurrent) associated with the root
canal system. A thorough clinical and periodontal exami-
nation should be performed. At this time the type, angula-
tion, and number of subsequent radiographs are deter-
mined. All sinus tracts and pockets greater than 6.0 mm
should be traced on these films. Usually a bite-wing and
several periapical radiographs are taken. The resulting in-
formation (Box 8-2) is then combined and synthesized to
produce a mental three-dimensional reconstruction of the
tooth. As the clinician performs the evaluation, he or she
forms an impression that attempts to differentiate between
previously inadequate treatment and treatment compro-
mised by clinical limitations. When possible, the dentist
who performed the original treatment should be contacted.
Their records and radiographs may provide a valued per-
*Each canal system in a multicanaled tooth must be considered separately.
spective on the nature of the problem and the quality of
care provided. Restorative dentists should also be involved
at this time in anticipation of their role in retreatment. (Boxes 8-3 and 8-4). Occlusal and orthodontic considera-
As endodontic retreatment is considered, so too is the tions may also influence the decision process (Box 8-5).
ability to restore the tooth after retreatment. Interdiscipli- With the new diagnosis, the clinician forms an impression as
nary treatment planning is as important as endodontic di- to how retreatment and restoration will benefit the patient.
agnosis. Realistically, almost any tooth can be retreated, but What are the endodontic expectations to:
restoring it to biologic health and function may not always
be possible. This treatment planning process focuses on 1. Improve the original debridement and canal
periodontal conditions and remaining tooth structure shape.
 Chapter Eight
BOX 8-4
Prosthetic Considerations
Crown-root ratio
Root width, depth, and proximity
Amount and quality of remaining tooth structure
Ability to place an adequate ferrule or margins
Occlusal load and function
Floor to furcal distance, perforations (repairs)
Relationship to the entire restorative picture
BOX 8-5
Orthodontic Considerations
Patient goals, desires, esthetics
Overall control of inflammatory dental disease
Occlusal stability: function and parafunction
Periodontal disease and tooth position
Abutment inclination
Potential pontic or implant spaces
2. Debride newly accessed and contaminated regions
of the canal system.
3. Improve on the radicular filling, restoration, and
function.
Recently, critical abutments compromised in many
respects have been considered for extraction and implant
placement. The decision to retreat should also embrace
the patient's financial and emotional considerations.
After pretreatment assessment and diagnosis the fo-
cus shifts to the operator, patient, and restoring dentist.
For the operator, each retreatment procedure is unique,
frequently testing his or her limits of ingenuity, flexibility,
and persistence. Rather than a single magic "silver bul-
let" treatment, a deliberate, logical, stepwise approach
Retreatment 119
is more successful. Treatment, which sometimes seems
tedious and time-consuming, presents an exciting chal-
lenge to the retreating dentist. The operator should never
underestimate the potential difficulty of the procedure.
If doubt exists regarding professional ability, armamen-
tarium, time apportionment, expectations, or compen-
sation, referral to an experienced colleague is
indicated.
After giving initial consent to treatment the patient
must remain an informed partner as the prognosis
evolves during retreatment. A mid-treatment complica
tion may arise or the outcome may be less than antici-
pated. A surgical approach or extraction may be neces-
sary. In all instances, ongoing forthright communication
with the patient is essential. This intimate communica-
tion must also be maintained with the restoring dentist.
After endodontic treatment the outcome must be ap-
praised; the tooth must be restored and then evaluated
on recall to confirm success. Root canal treatment is
never complete until the tooth is restored to function.
CORC>NAL DISASSEMBLY: REGAINING
ACCESS TO THE CHAMBER FLOOR
With a plan in place, retreatment procedures may com-
mence. A common finding on initiation of retreatment
procedures is that the original access preparation was
too small and restrictive. If maximal straight-line access
was not achieved, it probably contributed to subsequent
deficiencies in instrumentation, debridement, and obtu-
ration. Physically and visually restricted access prepara-
tions make the search for additional canals more diffi-
cult. These considerations frequently lead to the removal
of existing restorations. If a new restoration is planned
or a temporary restoration is already in place, this pro-
cedure should be relatively uncomplicated. If a fracture is
suspected, the clinician should remove the entire restora-
tion, apply dye stain, transilluminate, and view with
magnification. Active caries must always be removed,
and faulty, leaking restorations should be replaced or re-
paired. If the existing restoration is to be maintained,
consideration must be given to its removal or careful,
nondestructive penetration (often without a rubber dam
so the clinician can observe prosthetic realignment). Oc-
casionally the existing restoration can be removed and
then temporarily replaced for esthetics or function after
treatment (Box 8-6).
Beneath the coronal restoration the operator should
anticipate a filling, core material, or a post and core com-
bination. With adequate provisional access, core and filling
materials can be rapidly removed with burs. If canal filling
materials such as carriers, silver cones, or posts extend into
the chamber and core material, the clinician should at-
tempt to work around them, preserving their coronal ex-
tensions. Methods to achieve this include changing the -bur-
cutting direction (Figure 8-1) and isolating posts by
ultrasonics (Figure 8-2). Material on the walls and floor
 120 Color Atlas o f Endodontics
FIGURE 8-1 Bur-cutting directions.
should be chipped free with ultrasonics, magnification, il-
lumination, and preferably microscopy.
Careful observation and particular care are necessary
to detect the presence of titanium alloy posts and carri-
ers.2 Their radiopacity is similar to that of most radicular
filling materials. Clinically their dull gray color usually
distinguishes them from surrounding materials.
As access is reestablished, microscopy and its atten-
dant illumination permit visualization of anatomic land-
marks and identification and location of the root canals.
The "map" on a chamber floor or the color of the dentin
further assists in localization of the canal orifices. Local-
ization may be followed by occlusal access modifications
for better straight-line access. Unless a post or radicular
filling material is obviously loose or completely blocking
exploration, the clinician should not attempt to remove
it. This phase of retreatment should be limited to identi-
fication of orifices and exposure of the chamber floor. Co-
pious irrigation and aspiration are invaluable. Organic
material in an undiscovered orifice often demonstrates a
"bubble trail" on the chamber floor as the sodium
hypochlorite breaks down the tissues and effervesces.
Cast posts, cast interlocking posts, and Richmond
crowns are initially exposed in a similar manner, with
the clinician using a bur to remove coronal or core struc-
FIGURE 8-2 Post isolated using ultrasonics.
ture until the tooth-metal interface can be visualized near
the orifice for each canal.
POST REMOVAL
In 1926, Kells 3 suggested using two strong magnets to
remove cemented posts. Present techniques have given
clinicians a far greater advantage. The clinician must
consider all the factors that significantly influence post
retention-length, shape, surface characteristics, cemen-
tation media, and active or passive placement-before
attempting post removal. Large post diameters, likeli-
hood of fracture, and the risk of removing too much
tooth structure are other notable concerns. Occasionally,
when a post seems adequate but difficult to remove and
the endodontics for that root is questionable, the post
may be retained and a surgical approach considered.
Pretreatment radiographs from various angles help
identify posts that are close to or actually perforating a
root. Sound practice frequently dictates the evaluation of a
post with an apex locator before removal. After removal
the clinician can use transillumination, microscopy, and
paper points to evaluate the post space.4, Even when per-
5
foration repairs are possible, structural losses may have ex-
cessively weakened the root, predisposing it to fracture.
 Chapter Eight
FIGURE 8-3 The clinician can use Steiglitz forceps to engage the
post while applying ultrasonics.
Unless the post is obviously loose, reduction of post re-
tention should follow post isolation .6 Ultrasonic vibration
can be applied to the coronal extension of the post. Vibra-
tion applied in this manner has been shown to reduce post
retention substantially and facilitate removal. If the post
shows signs of disintegration when touched by ultrasonic
tips, the clinician can clamp the post with a hemostat or
Steiglitz and vibrate on the forceps (Figure 8-3). The first
motion detected is usually rotational. A gentle drawing
force on the hemostat, with continued ultrasonic vibration,
should complete the removal process. Troughing the ce-
ment line around posts may also help reduce retention
( Figure 8-4). Because canals are not perfectly round and
no post fits precisely, a cement line or space that small, del-
icate ultrasonic tips can penetrate should be evident with
magnification (Figure 8-5). When using these smaller ul-
trasonic tips, the clinician should lower the power setting
to minimize instrument breakage. A primary objective is
to preserve as much sound dentin as possible. Small hand
files with solvents may also be used adjacent to recalcitrant
posts. These files can be ultrasonically energized . 7 If ultra-
sonics and discrete troughing fail to dislodge a post, a va-
riety of post removal devices may be used (Figure 8-6).
These devices generally work using principles similar to
that of a corkscrew. The post is engaged and pulled from
the fulcrum, the tooth (Figure 8-7). When the use of a re-
moval system is anticipated, reduction and tapping
(threading) of the post should be accomplished before any
signs of mobility occur.
Retreatment 121
FIGURE 8-4 Troughing cement around post.
4. Prepare the post, reducing it to fit the coinciding tap
size.
5. Tap the post in a counterclockwise (preferred) or
clockwise direction, depending on the system
6. Remove the threading device, place a padded ring
on the tap, and thread it back onto the post.
7. Place the extractor, engaging the tap between the
padded ring and tap knob.
8. Activate removal device and turn removal knob or
extractor clockwise in combination with ultrasonics
delivered directly to the device.
9. Remove post, completing the first step of nonsurgical
retreatment.
Occasionally clinicians must alternate between ultra-
sonically activating this assembly and incrementally in-
creasing the drawing force. They must be patient and try
to avoid excess tension that can lead to root fractures.
Repeated, deeper troughing may also be necessary to fur-
ther weaken and break cement bonds. If magnification
and visualization are adequate, drilling a post out with a
small, high-speed, long-shank round bur can be a tedious
but effective last resort.
As radicular disassembly progresses, the clinician
can cover other open canal orifices with cotton, espe-
cially when modifying the access preparation through a
restoration. This will help minimize debris from be-
coming an additional canal obstacle.
THE REMOVAL OF RADICULAR FILLING
MATERIAL OR OBSTRUCTIONS
The following basic principles must be considered as
radicular filling materials are removed:
1. The hardness or consistency of a nonmetallic filling
or the ability to remove an intracanal material can-
not be determined radiographically.
122 Color Atlas of Endodontics
FIGURE 8-5 Ultrasonic tip assortment.
2. Removal of a previous filling material is usually eas-
ier if the root canal treatment is failing because of re-
current leakage.
3. No canal space is naturally round.
4. Access to the apex and patency are necessary to
achieve the root goals of cleaning and shaping the
canal system.
5. The philosophy behind the "crown-down" ap-
proach' is most applicable to the removal of radicu-
lar filling materials or obstructions.
6. All preparations increase in size during retreatment.
Usually the coronal third demonstrates the greatest
enlargement. 9
7. Canals that initially deviate from their natural cen-
terline tend to continue to deviate in the same direc-
tion during retreatment. Areas not instrumented
during initial treatment are more difficult to contact
during retreatment.
8. Irrigation and disinfection must be emphasized be-
cause all canals that are retreated should be consid-
ered contaminated with microorganisms.
9. Solvents, while useful, can interfere with debridement.
10. All methods of instrumentation and removal leave
debris remaining in the canals.
11. Open canals not being treated should be protected
or covered.
12. Patience is a virtue.
The three categories of materials most commonly con-
sidered during retreatment are pastes, semisolids with seal-
ers, and solids placed with or without sealers (Box 8-7).
Removal o f Paste Fillings
Injectable paste filling materials may be soft and pene-
trable or firm and resistant to entry. These materials may
FIGURE 8-6 Post removal devices.
or may not extend to the apical portion of the canals.
Soft materials, usually zinc oxide and eugenol base ma-
terials, may be removed using small hand files with gen-
tle instrumentation (traditionally a reaming or balanced
force action) and copious irrigation with sodium
hypochlorite (Na OCI). The actual constituents of many
pastes may remain a mystery because formulations are
variable. Some may contain extremely toxic materials
such as paraformaldehyde, lead, and arsenic. The clini-
cian should take great care to remove as much of the
previous filling material as possible before attempting to
proceed with definitive apical instrumentation.
Pastes, which are not initially penetrable, should be
exposed to solvents such as chloroform (Box 8-8). Any
open canal should be covered before the chamber is
flooded with solvent. A stiff instrument such as a DG-
16 or a clipped #25 K-filer° can be used to determine sol-
ubility. If the material is soluble, the clinician should con-
tinue using the solvent until the material has been
bypassed and removed and then return to NaOCI irriga-
tion as soon as practical. If the material is hard and in-
soluble, the operator may reconsider the value and risks
associated with retreating that canal. How much mater-
ial will be penetrated? Are the canals curved? Is surgery
a better option? If the clinician should discuss all these
risks with the patient. If the patient and clinician decide
to continue, ultrasonics, magnification, and illumination
can be used to progress through the material. Clipped
files are most useful. Radiographs are appropriate
to determine the direction of instrumentation. Once
"through," the feel of the canal on "the other side" is
most rewarding. If the clinician is not successful pene-
trating or removing all the material, he or she may fill
the working space conventionally or use it as a post
space. Root-end surgery may be indicated.
 Cbapter Eight Retreatrnent 12 3

FIGURE 8-7 Post removal system technique. A, Post isolation (using bur). B, Gross removal of
build-up (using large ultrasonic tip). C, Detailed removal of build-up (using small ultrasonic tip).
D, Post tapping (counterclockwise). E, Screwing tap on with rubber cushion. F, Attachment of re-
moval fork to tap and activation. G, Post removal.
124 Color Atlas o f Endodontics
Removing Gutta-Percha Core Materials
Mechanical and/or solvent dissolution techniques can be
used to remove gutta-percha and sealer. The preferred
technique is mechanical because it allows for better de-
bris removal. The use of solvents substantially compli-
cates debridement. When solvents are used to remove
gutta-percha or pastes, the dissolved infected debris from
these materials is more likely to flow into and coat inac-
cessible canal irregularities and/or penetrate into the
periradicular tissues.
The decision to use one or both techniques hinges on
three factors:
1. The existing condensation quality-Densely filled
canals may require a solvent to facilitate penetration.
Poorly condensed fillings can usually be removed me-
chanically. Usually the coronal aspect of any canal is
most densely compacted.
2. The length o f the existing filling material-The use of
solvents to dissolve filling materials in the apical third
of the canal system risks pushing these materials into
the periradicular tissues. The use of solvents in the
apical third with an overextended cone all but ensures
that the overextended segment will be severed and re-
main in the periradicular tissues.
3. The tooth's root morphology, canal shape, size, and
curvature-Mechanical techniques remove more
dentin than solvent approaches. With a compara-
tively straight and substantial root, the clinician may
be able to remove all of the gutta-percha using rotary
instrumentation. In contrast, a densely filled curved
canal such as the mesiobuccal root of a maxillary first
molar may require solvents to reduce the risk of api-
cal transportation or furcal strip perforation.
A mechanical removal technique usually begins with
rotary instrumentation (using Gates Glidden drills or
nickel-titanium files) to rapidly remove the coronal por-
tion of the gutta-percha. The canal is larger coronally
and straight enough to tolerate these procedures. Mini-
mal pressure is exerted as smaller sizes are used to
progress apically in a crown-down manner. The clinician
should promptly remove any material adherent to the
rotary instrument and carefully cut away from furcal
concavities. Alternatively, a heat source with diminish-
i ng sizes of heat carriers may be used to remove the
gutta-percha.
 Chapter Eight Retreatment
As the coronal bulk of material is removed, penetra-
tion of the apical radicular filling becomes possible. Us-
ing an appropriately curved, short ( 21 mm) size 15 or
20 K-file with a repeated reaming action, the clinician
should be able to instrument next to the previous filling
material. He or she should not file, force, or push in-
struments apically. Frequently, the operator will sense
that it is possible to almost "screw the file in." If this is
feasible, the operator should be careful that the file is not
placed so aggressively as to demonstrate "spring-back"
when the handle is released. Ideally the entire gutta-
percha filling will be bypassed with size 20 or larger
K-files. The clinician can use an apex locator to estimate
the file position if necessary. Frequent and generous irri-
gation with NaOCI is indicated. Old gutta-percha fill-
ings are likely to be brittle. In such situations the gutta-
percha will seem to shred and break into small pieces as
the path alongside it is created and debris is removed.
After establishing a path, the clinician chooses the next
larger Hedstrom file (at least a size 20) and rotates it
clockwise alongside the filling material, avoiding spring-
back. Although this file will engage dentin, it will pref-
erentially embed its flutes in the softer gutta-percha.
With controlled force, the clinician removes the Hed-
strom file as though it were a corkscrew, turning coun-
terclockwise as necessary if too much resistance is en-
countered. The entire gutta-percha mass may release, but
more often small fragments will be removed each time
this process is repeated. The clinician may consider a
larger file size if the canal anatomy permits but should be
careful not to sever overextended segments. When work-
ing close to the estimated working distance, the clinician
can take a radiograph with the file in place. Ideally, all
apical filling materials should be removed. The value of
removing materials that remain in the middle and coro-
nal thirds must be carefully weighed against concerns for
preservation of tooth structure.
Many solvents have been proposed to aid in retreat-
ment of gutta-percha fillings. The authors of this chapter
prefer chloroform, but less volatile solvents such as
d-limonene (a xylene substitute)" are being investigated
and may prove safer. A solvent dissolution approach
usually begins, as does the mechanical approach, with
the bulk of materials being removed by rotary instru-
mentation. This action creates a coronal space or reser-
voir where the solvent can be deposited. Initially, a 21-
mm 15 or 20 K-file can be used to penetrate and remove
the dissolving mass of filling material. The instrument
flutes should be cleaned after each pass, with the solvent
being replenished as it evaporates. As the material fur-
ther softens, Hedstrom files may be used to expedite re-
moval. Slowly and without forcing, the clinician can use
precurved files to work through the previous filling. Un-
less it is necessary for visualization, irrigation is not in-
dicated because it will dilute and diminish the solvent's
effectiveness. As the apical extent of the filling is ap-
125
proached, the clinician may attempt to complete the
process mechanically. If this is not possible, he or she
may continue with the solvent while using files with a
reaming action to minimize pushing debris apically. Af-
ter the file has bypassed or is completely alongside the
filling material, he or she can begin irrigating with
NaOCI and follow the steps of mechanical removal.
Removal o f Silver Cones
Once an extremely popular filling material, silver cones
were used to fill canals for either their entire length or
with an apical "sectional," "twist-off," or "plug" tech-
nique (Figure 8-8). To remove a silver cone that projects
into the chamber from an orifice, the clinician begins by
carefully exposing the coronal extent of the cone down
to the level of the orifice. Gutta-percha or sealer. sur-
rounding the cone can easily be picked or chipped away
with explorers, spoon excavators, and solvents. How-
ever, the clinician must exercise extreme care not to re-
peatedly bend or flex the free end of this soft metal, es-
pecially the smaller sizes. Bending often leads to
breakage at or below the level of the orifice, further com-
plicating removal. If the cones are embedded in amal-
gam, the clinician should remove the core as though it
contained a post, leaving the silver cone surrounded by
small amounts of alloy (Figure 8-9). Sometimes coronal
portions of silver cones are folded to the chamber floor
and covered with a zinc phosphate base. Ultrasonics,
magnification, and illumination are most useful to ex-
pose these silver cones. The clinician should be careful
to prevent direct contact between ultrasonic tips and
silver cones because the soft silver will disintegrate. Un-
less the cone displays visible motion (not to be confused
with flexure of the coronal free end), the initial urge to
grasp the cone and pull on it should be resisted. Instead,
FIGURE 8-8 Twist-off silver point device.
12 6 Color Atlas o f Endodontics
FIGURE 8-9 A, Silver cone with amalgam remnants. B, Amalgam removal using ultrasonics.
FIGURE 8-10 Modified Gates Glidden drills.
working with short-length, 21-mm 15 or 20 K-files and
solvents, the clinician can begin to create a pathway
alongside of the cone. If the cone remains secure, another
path can be initiated, ideally on the opposite side of the
cone. If possible, these paths should completely bypass
the silver cone. The route of the path can be confirmed
with a radiograph or an apex locator. In this classic ap-
proach, still using the solvent, the clinician selects a size
20 or larger Hedstrom file and turns it clockwise into the
path, engaging both the cone and dentin. If spring-back
is detected in the handle, the file must be turned coun-
terclockwise until the perception is lost. The clinician
then attempts to withdraw the Hedstrom file, hopefully
engaging the silver cone. If the cone has not been dis-
lodged, additional channels may be made alongside it.
Frequently more than one Hedstrom file is placed and
their coronal ends are braided before they are with-
drawn. Many clinicians use ultrasonics to further loosen
the cones as the pathways are created. The energy can
be delivered in two ways, which prevents disintegra-
tion of the soft silver. The coronal free end of the cone
can be grasped with a Steiglitz or similar forceps. The
Steiglitz or forceps (not the silver cone) can then be en-
ergized with an ultrasonic tip while a gentle constant
drawing force is exerted. Additionally, a small file and
solvent or one of the smaller ultrasonic tips can be
placed in the path and energized. Using lower power set-
tings reduces the potential for breakage of these delicate
tips. Most silver cones yield to a combination of patience
and repetition of these efforts. If the coronal free end
breaks or the silver cone was placed by an apical
method, it should be managed in the same way as a bro-
ken instrument. If an object is in the coronal third, the
clinician may attempt to bypass it or engage and remove
it with a Hedstrom file. Careful ultrasonic vibration is
usually helpful. If the canal is straight and substantial
root structure remains, an extraction tube technique can
be used to regain attachment to the coronal free end.
However, these devices cannot accommodate curves and
are rarely used in the restricted confines of the apical
third.
Staging
Metallic objects and apically placed silver cones may
also be approached by staging. In this technique, files or
modified Gates Glidden drills (Figure 8-10) are used to
create a platform or stage at the coronal aspect of the
object. From this location, with the use of magnification,
micro-irrigation, and ultrasonics, the clinician may be
able to trough around the coronal aspect of the object.
This action may vibrate the object free, allowing for its
removal or enabling it to be bypassed by an instrument.
An extraction tube approach may also be possible. Ac-
cessory fiberoptic transillumination through the buccal
soft tissues can substantially facilitate this tedious intra-
canal work.
 Chapter Eight
The removal of fractured nickel-titanium instruments
and gutta-percha carriers is further complicated by their
predisposition to disintegrate on ultrasonic contact.
More delicate ultrasonic tips used with lower power set-
tings and controlled air flow through micro-irrigation sy-
ringes are used to facilitate the precise troughing neces-
sary to remove nickel-titanium objects, which have the
tendency to spring back toward the canal wall because
of their material memory.
Removal o f Gutta-Percha
Carrier Devices
The first carrier devices 12 were made with stainless steel
shafts and coated with gutta-percha. These carriers be-
came available commercially in 1988 and have gained
rapid acceptance in general dentistry. The manufactur-
ers advocate their placement using either full-length or
sectional filling techniques that allow for post spaces. In
contrast to the more recently introduced gray-black
nickel-titanium carriers, the original silver-colored stain-
less steel carriers are easily distinguished radiographi-
cally.2 If the stainless steel carrier extends into the cham-
ber it can be removed in a manner similar to that used
for silver cones. The gutta-percha and sealer surrounding
the coronal aspect of the carrier can initially be removed
mechanically with small spoon excavators and Hed-
strom files. If necessary a solvent can be used, but the
dissolved gutta-percha will become runny and difficult
to remove. After adequately exposing the carrier, the
clinician can grasp it with a Steiglitz and heat the entire
assembly while slowly drawing the carrier from the heat-
softened gutta-percha. The remaining gutta-percha
should be removed mechanically without a solvent. If a
sectional technique has been used, removal efforts must
follow the techniques used for broken instruments or
apical silver cones. Root anatomy may necessitate the
consideration of surgical retreatment.
More recently, manufacturers have begun to market
two types of plastic carriers. Carrier sizes 30 or smaller
are made of an insoluble liquid crystal plastic. Carrier
sizes 35 and larger are made of polysulfone plastic,
which is soluble in chloroform, and related solvents.
Neither the plastic nor the nickel-titanium carriers can
be distinguished radiographically from their gutta-
percha coatings (Box 8-9). Because general dentists com-
plete more than 90% of all endodontic procedures
( many of them using carrier-filling techniques), the re-
treating dentist must always anticipate the potential for
such a radiographically occult core material.
Removal o f Plastic Core Materials
For canals containing plastic carriers, the clinician
should initially attempt to remove the carrier in its en-
tirety by grasping it with a Steiglitz or Peet's forceps and
carefully drawing it coronally. If this is not successful, a
solvent or heat source can be used to soften the coronal
Retreatment 12 7
From Kleier DJ, Shibilski K, Averbach RE: Radiographic appearance of titanium posts
i n endodontically treated teeth, l Endodon 25(2):128, 1999.
gutta-percha. Plastic carriers in sizes 35 and larger are
soluble in solvents such as chloroform. Next, using firm
pressure the clinician turns one or more Hedstrom files
clockwise alongside the plastic core, allowing the flutes
to engage the carrier. Once they are engaged, the file and
carrier are drawn coronally. If this is unsuccessful, the
clinician uses a low-speed, high-torque handpiece to cre-
ate a deeper channel alongside the plastic carrier and
then carefully repeats the Hedstrom file/solvent tech-
nique until all the material is removed or anatomic lim-
itations are encountered.
Another removal technique uses a .04 tapered size 30
file in a low-speed, high-torque handpiece rotating at ap-
proximately 600 RPM alongside the carrier. After re-
moving the instrument, the clinician repeats the proce-
dure with a file of even greater taper. If more aggressively
tapered files are not available, .04 tapered 35 or 40 files
may be used. The clinician can proceed with the wider
tapered file at 300 RPM into the same channel prepara-
tion. The wider taper should engage the carrier and help
dislodge it coronally. Generally, it does not remove the
carrier in a single stroke. If one side is completed and
the carrier is not loose, the clinician then proceeds with
the same technique on the opposite side of the canal. Af-
ter the carrier is dislodged, a working length film is ob-
tained and the balance of the apical filling material is
removed.
Removal o f Nickel-Titanium
Core Materials
The retreating dentist must remember that these carriers
are radiographically difficult to discern and will shatter
or disintegrate if excess ultrasonic energy is applied. If the
gray-colored carrier extends into the chamber, removal is
best accomplished in a manner similar to that used for its
stainless steel counterpart, using heat to soften the sur-
rounding gutta-percha. If the device is located in the
128 Color Atlas o f Endodontics
middle or apical third of the canal, a sectional silver cone
approach is necessary. Surgical treatment may need to be
considered. In all instances a nonjudgmental, matter-of-
fact approach is essential as the patient is advised of
changes in prognosis and possible outcomes.
REGAINING ACCESS TO THE APEX:
REINSTRUMENTATION, IRRIGATION,
DEBRIDEMENT, AND DISINFECTION
After removing previous filling materials and obstruc-
tions, the clinician must re-establish access to the apex
along the path of the original canal. It is unusual to find
a readily patent and negotiable canal "on the other
side." If this were the case, the operator could proceed
with the usual techniques of cleaning and shaping,
while placing particular emphasis on irrigation to
debride and disinfect. Working length radiographs are
essential to evaluate length and preparation. Informa-
tion provided by electronic measuring devices is com-
plementary to these radiographs. As the final cleaning
and apical shaping continues, the operator must recall
that continued preparation naturally tends to deviate
from the original centerline of the canal, especially in
the coronal third.
If the previous filling materials were under-extended,
the goal of apical instrumentation may be complicated
by the following canal abnormalities:
1. Blockages with dentinal and/or pulpal debris
2. Dentistogenic complications such as ledges and
transportation
3. Calcifications
4. Anatomic complexities
In the worst case scenario, a canal will feel solidly
blocked and impenetrable. Recalling basic principles of
endodontic instrumentation, the operator should choose
a short (21-mm, size .08, .10, or .15) file size, irrigate,
and gently feel for a "catch." Usually a small J hook is
placed at the instrument's tip and a gradual bend is
placed throughout the instrument's length. While ex-
ploring the canal, the clinician should resist the natural
tendency to push more aggressively, which will only
complicate a blockage or ledge. Frequent irrigation
should be employed to remove debris. If no catch is de-
tected, the canal should be dried and irrigated with a
chelating agent such as 17% ethylenediaminetetraacetic
acid (EDTA) in aqueous solution. As gentle exploration
continues, the clinician should curve and recurve the file,
while ascertaining that no coronal or radicular access re-
strictions impede the motion of the file. Irrigation should
not be performed with NaOCI because it will neutralize
the effect of the chelating agent. If several canals are be-
ing re-entered and the first yields no initial signs of
progress, the clinician should leave EDTA in place and
proceed to work on another canal. Without rushing, the
clinician continues to explore each canal for even the
slightest catch and gently pursues it with the smallest file
sizes when a catch manifests. This gentle but persistent
effort rarely results in perforation, even with EDTA. The
clinician should conscientiously discard worn instru-
ments while replenishing the EDTA. After the estimated
distance has been achieved, it can be enlarged to a size
15 file and a working radiograph can be taken to con-
firm length and file position. If a previously blocked
canal continues to resist apical instrumentation, a
clipped file approach may carefully be attempted.10 Typ-
ically about 1 to 2 mm are clipped from the tip of a 21-
mm size 15 file. This procedure leaves the tip with sharp
cutting edges that can be used with a back-and-forth,
auger-like motion. 13 With this technique the clinician
may be able to work through the resistant blockage. Dis-
cretion normally dictates that only 1 to 2 mm of length
should be attempted in this manner before the clinician
gently feels for the natural canal again with a small, un-
clipped, curved file. Radiographs are essential to monitor
the files' progress, especially around curves. After the
original canal has been re-established, hand or rotary in-
strumentation techniques can be used to finish shaping
the preparation.
Considerable emphasis must be placed on debride-
ment, irrigation, and finally disinfection. The retreat-
ing dentist must remove as much of the contaminated
previous materials as possible, as well as debris created
by new instrumentation. Any motion that might push
this debris apically should be avoided. As the prepara-
tion nears completion, the clinician must undertake a
focused search for any additional untreated canals. The
operating microscope offers ideal illumination and v1s-
ibility to accomplish all of these goals. Anatomic
grooves and dentin coloration can also guide the oper-
ator in locating additional canals. In the apical area,
bubble trails and careful tactile exploration with ap-
propriately curved small files may reveal patent apical
ramifications. The radiographic file position (centered
or not) within the root is also an excellent indicator of
additional canals.
All authors concede that complete debridement of
the root canal system is impossible. During retreatment,
remnants of previous filling materials will always remain
out of reach of reasonable instrumentation. The operator
must assume that these uninstrumented areas and their
adjacent dentinal tubules are contaminated with mi-
croorganisms. To date, the consensus of most au-
thors 14,11 suggests that a conscious effort at further canal
disinfection must follow cleaning and shaping and pre-
cede the filling appointment. At this time, placement of
an intracanal dressing such as calcium hydroxide 14
( CaOH) 14 or an antibiotic-containing fiber 15 for a period
of at least 1 week seems most appropriate. A temporary
restoration at least 4 to 5 mm thick is then placed against
the sound walls of the access preparation. 16
 Chapter Eight
FILLING, PROGNOSIS,
AND POSTTREATMENT RESPONSIBILITIES
All filling techniques attempt to prevent recurrent leak-
age and seal in or entomb debris that cannot be removed
from the root canal system. The clinical conceptualiza-
tion of a root canal filling should be that of a maze on a
micrometer scale. No ionic or covalent bonds come into
play, only physical interfaces among dentin, sealer, and
gutta-percha. All obturation techniques leak. 17 As long
as clinicians continue to fill canals in a manner that fa-
cilitates nonsurgical retreatment, they will never mea-
surably improve on existing obturation techniques. The
time-honored adage, "It's what you take out, not what
you put in," is as true today as it was 100 years ago (see
Chapter 7). The reader is left to choose an appropriate
filling technique.
The completion of canal obturation leaves the clini-
cian with a sense of prognosis. As part of the ongoing
process of consent, treatment outcomes must be con-
veyed to the patient. Additional referrals for periodontal
or related procedures must be arranged if they were not
anticipated preoperatively. For the patient, filling is usu-
ally perceived as completion, the end of the root canal
treatment. They have survived, and usually their worst
fears have passed uneventfully. They are also comfort-
able and all too frequently complacent, wishing to take a
break from treatment. Beyond providing any required
postoperative management (e.g., pain and/or infection
control), the clinician also has a responsibility to ensure
that the patient returns promptly for definitive restora-
tive procedures. When a specialist provides treatment,
this process may begin as a phone call and/or a referral
acknowledgment and a radiograph.
Posttreatment follow-up is as essential as retreatment
planning. If any delays in the restorative process are an-
ticipated, a more definitive temporary restoration such as
reinforced zinc oxide and eugenol or a light-cured inter-
mediate composite should be placed. Application of an
orthodontic band to reduce the possibility of fracture or
placement of the core build-up and a temporary crown is
frequently indicated. Loss of a temporary restoration re-
quires immediate replacement. Treatment must never be
considered complete until the tooth is restored to func-
tion. Endodontic recall examinations should be scheduled
at any time if signs or symptoms develop and planned
routinely at 1 and 2 or more years.
SURGICAL RETREATMENT
Surgical endodontic retreatment procedures may be con-
sidered if nonsurgical retreatment approaches fail or are
unable to resolve treatment concerns or if a biopsy is in-
dicated (see Chapter 10). Accurate diagnosis and the un-
derstanding that root-end surgery is never superior to
proficiently accomplished nonsurgical treatment are fun-
damental to the best possible outcome.
Retreatment 12 9
Even though few medical or anatomic contraindica-
tions to surgical retreatment exist, this does not diminish
the value of accurate diagnosis and careful treatment
planning. These preparations must be approached with
extreme care and substantial empathy for the patient.
Although periradicular surgical retreatment is the
most common approach, replantation may also be con-
sidered. Alternative treatment plan options, including the
use of three-unit bridges or the placement of implants,
must be addressed before a surgical procedure is recom-
mended. The etiology of failure must be identified when
possible. The persistence of microorganisms or their
toxic products must be considered in light of the poten-
tial to remove or entomb these irritants. Operators must
always consider vertical root fractures when apparently
well-done nonsurgical and surgical endodontic proce-
dures fail repeatedly. Other possibilities include unfilled
sections of canal. In this instance, if a surgical approach
is indicated, instrumentation through the root-end and
filling of these canals should be considered in addition
to resection and root-end filling.1 8
From an operative perspective, significant fibrosis
from previous healing may complicate flap elevation in
cases previously treated surgically. A biopsy of the peri
radicular tissues is essential. With careful respect to the
crown-to-root ratio, further root resection is usually ap-
propriate. When a root-end filling material needs to be
removed, appropriate crypt management is essential to
prevent scattering of the filling material. After the root
end has been prepared, dye staining and detailed micro-
scopic examination are required before root-end instru-
mentation, root-end filling, and closure. Postoperative
care must be timely and appropriate. It is axiomatic that
recalls are essential.
References
1. American Association of Endodontists: AAE glossary, contempo-
rary terminology for endodontics, ed 8, Chicago, 1998, American
Association of Endodontists.
2. Kleier D, Shibilski K, Averbach R: Radiographic appearance of ti-
tanium posts in endodontically treated teeth, J Endodon 25:128,
1999.
3. Kells CE: Three score years and nine, Chicago, 1926, Lakeside
Press.
4. Bruder G et al: Perforation repairs, NY State Dent J 65:26, 1999.
5. Nahmias Y, Aurelio JA, Gerstein H: Expanded use of the electronic
canal length measuring devices, J Endodon 9:347, 1983.
6. Johnson WT, Leary JM, Boyer DB: effect of ultrasonic vibration
on post removal in extracted human premolar teeth, J Endodon
22:487, 1996.
7. Krell KV, Fuller MW, Scott GL: The conservative retrieval of silver
cones in difficult cases, J Endodon 10:269, 1984.
8. Morgan L, Montgomery S: An evaluation of the crown-down
pressureless technique, J Endodon 10:491, 1984.
9. Wilcox LR, van Surksum R: Endodontic retreatment in large and
small straight canals, J Endodon 17:119, 1991.
10. Fachin EVF, Wenckus C, Ann CE: Retreatment using a modified-
tip instrument, J Endodon 21:425, 1995.
130 Color Atlas o f Endodontics
TEB SINA CHEHR
(4070932 - 6418770)
132 Color Atlas o f Endodontics
FIGURE 9-1 A, Teeth #6 and #7 restored with cast post and core foundations. B, Root canal treat-
ment, cast post and cores, and porcelain fused to metal crowns have restored the maxillary right ca-
nine and lateral incisor to function and esthetics.
crown lengthening, orthodontic extrusion, or extraction.
Key abutment teeth in a patient with extensive fixed re-
construction should have a good endodontic prognosis
before a definitive restoration is placed. The clinician
should also consider the need for elective root canal
treatment and retreatment before placing the definitive
restoration. Endodontically treated teeth should proba-
bly not be used as abutments for fixed partial dentures
with more than one pontic because the greater load
placed on the prosthesis may render them more likely to
fracture.3 Anterior endodontically treated teeth used as
abutments for fixed partial dentures should be restored
with cast post and core restorations. Endodontically
treated teeth should not be used as abutments for distal
extension partial dentures because they are more than
four times as likely to fail than pulpless teeth not serving
as abutments. 3 Nyman and Lindhe noted that fractures
occurred more frequently in teeth treated endodontically
and then used as abutments for free end segments. 4
Other studies support this finding as well and caution
against the use of endodontically treated teeth as distal
extension abutments. 5,6
Structure of Endodontically Treated Teeth
Papa and others7 found no significant difference in the
moisture content between matched pairs of endodonti-
cally treated and vital teeth. Vital dentin exhibited a
moisture content of 12.35%, whereas dentin from en-
dodontically treated teeth had a moisture content of
12.10%. Huang et al 8 compared the mechanical proper-
ties of human dentin from treated pulpless teeth with
dentin from normal vital teeth and noted an insignificant
effect of endodontic treatment on compressive and ten-
sile strength of the dentin. Research by Reeh and col-
leagues9 compared the reduction in tooth stiffness in en-
dodontic and restorative procedures. The relative tooth
stiffness as a result of endodontic procedures was re-
duced by 5%; however, restorative procedures generated
stiffness loss between 20% and 63%. Many operative
preparations result in larger amounts of tooth structure
loss when compared with endodontic access prepara-
tions. The volume of tooth loss is perhaps the primary
factor in the decreased strength of endodontically treated
teeth.
Restoration of Endodontically
Treated Teeth
ANTERIOR TEETH. With only a conservative access open-
ing, anterior teeth can be restored with a resin restor-
ation. Placement of a post is not necessary when a
complete coverage restoration is not indicated. Post in-
stallation may inhibit attempts to bleach a discolored en-
dodontically treated tooth. Moreover, a post does not
strengthen the root. A retrospective study by Sorensen
and Martinoff10 showed no improvement in prognosis
for endodontically treated anterior teeth restored with a
post. Lovdahl and Nicolls" found that endodontically
treated maxillary central incisors with intact natural
crowns exhibiting access openings were stronger than
teeth restored with cast posts and cores or pin-retained
amalgams. Large interproximal restorations, incisal edge
fractures, or esthetic concerns may necessitate the place-
ment of a post and core, as well as full corona' coverage.'
POSTERIOR TEETH. A significant improvement is noted
in the clinical success of endodontic treatment of maxil-
lary and mandibular premolars and molars when coro-
nal coverage restorations are present. Full-coverage
crowns prevent fracture when occlusal forces act to sep-
arate the cusp tips.'° Crowns should generally be used
 Chapter Nine Restoration of the Endodontically Treated Tooth
on all endodontically treated posterior teeth.10 ,12 If sig-
nificant tooth structure has been retained, a crown may
be all the coverage required. If minimal structure re-
mains, a post may be necessary to help retain a founda-
tion before crown placement. If a crown cannot be
placed because of a patient's financial limitations, the
clinician should provide some other form of cuspal cov-
erage such as an amalgam onlay.
The Role o f Posts in the Restoration
o f Endodontically Treated Teeth
Most in vitro laboratory studies that have tested en-
dodontically treated teeth by applying force with a me-
chanical testing machine have shown that placement of a
post and core does not increase fracture resistance. Re-
searchers are in general agreement that posts do not re-
inforce endodontically treated teeth and actually weaken
the root. 1,13-17 The primary purpose of a post is to retain
a core that is used to retain the definitive restoration.
Types o f Posts
Posts can be made of a variety of materials (Figure 9-2).
Prefabricated posts are generally made of stainless steel,
platinum-gold-palladium, or titanium, but newer com-
positions include ceramic and carbon fiber. Cast custom
posts are usually cast from Type II or III gold alloy. Posts
can be categorized by mode of retention (active or pas-
sive) or shape (parallel or tapered). Laboratory studies
indicate that threaded (active) posts are the most reten-
tive, followed by cemented, serrated, parallel-sided
posts.18 Cemented, tapered posts are the least retentive.
Although threaded posts are the most retentive, they
place insertion stress on the root and can cause root
FIGURE 9-2 Posts can be made from various materials such as
stainless steel (A), esthetic carbon fiber (B), carbon fiber (C), and
ceramic (D).
135
fracture. The tapered post has a wedging effect that
also places stress on the root. Parallel serrated posts have
the advantage of good retention with uniformly distrib-
uted functional stresses.' A study by Felton," however,
demonstrated no statistical effects of post design on the
potential for root fracture and concluded that the
amount of remaining dentin and existing root morphol-
ogy may be determining factors for fracture resistance
during dowel placement in endodontically treated teeth.
Although retention is often evaluated in comparisons of
post and core systems, clinical experience indicates that
a post placed to adequate length is not likely to fail re-
gardless of the design. Intact, adequately placed posts are
difficult to remove when necessary.
Failure o f Post and Cores
Failures occur in several ways. The post may loosen, the
post and core complex may fracture or separate, or the
root may fracture. Approximately 3% to 10% of post
and core failures are attributable to root fractures. This
may be more likely in teeth that have lost some peri-
odontal support (Figure 9-3). A parallel, serrated (pas-
sive) post places less stress on the tooth root than ta-
pered or threaded (active) posts. Split and threaded
flexible posts do not reduce stress concentration dur-
ing function because the post is not flexible in three
dimensions. Cemented posts produce the least root
stress." Turner found that post loosening was the most
common type of failure among 100 failures examined.17
Sorensen's study of the records of 1273 endodontically
treated teeth yielding 246 total failures concluded that
36% of the failures were caused by post dislodgment,
33% were related to nonrestorable tooth fractures, 5%
were related to restorable tooth fractures, and 8% were
related to post perforations.10
Post Size and Length
Post length is unique and individualized for each case.
The clinician should have a thorough knowledge of root
morphology before placing a post. The effect of the em-
bedded depth of posts on retentive capacity has been
shown to be significant.20 The longer the post, the
greater the retention. A guideline of one half to three
quarters of the root length is often followed but may not
be reasonable for extremely long, short, narrow, or
curved roots. At a minimum, research has established
that the post length should be equal to or greater than
the crown length of the restored tooth (see Figure 9-3).
Retrospective clinical data on 1273 endodontically
treated and restored teeth demonstrated few failures for
posts that were as long as the crown or longer.'° At least
4 to 5 mm of gutta-percha should be left in the apical
portion of the canal to ensure an adequate seal. If this
guideline cannot be followed and the post is shorter than
the crown, extraction should be considered. The width
of the post should not be greater than one third of the
13 6 Color Atlas of Endodontics
A B
FIGURE 9-3 A, Tooth #12, which exhibited loss of periodontal support, was restored with a post
to a level unsupported by bone. B, The maxillary premolar eventually demonstrated a root fracture
at the apex of the post.
Ism
width of the root at any point along the dowel. Main-
taining a minimum of 1 mm of sound dentin around the
post is also advisable. Tjan 21 demonstrated that root
Valls with 2 or 3 mm of buccal dentin were less likely
to fracture than those having only 1 mm. Because of the
two-dimensional nature of radiographs, buccal-lingual
dimensions cannot be assessed and therefore the actual
amount of dentin present in the mesio-distal direction
may be smaller than the amount perceived. The clinician
should keep this in mind and carefully consider teeth
that have roots with fluting or depressions along the
mesial and distal surfaces. Smaller posts not only con-
serve tooth structure, but also provide increased resis-
tance to fracture compared with larger posts. 22
Preparation o f the Post Space As It Relates
to the Apical Seal and Microleakage
The post space may be prepared immediately after root
canal treatment is completed . 2 , 23 This procedure is a two-
step process. Gutta-percha should be removed incre-
mentally with a heated instrument or solvents before
canal enlargement. This method reduces the chance of
root perforation and microleakage 23 ( Figure 9-4), a
common sequela of gutta-percha removal during post
space preparation. The use of a heated instrument results
in significantly less leakage at both the 3 and 5 mm lev-
els of remaining gutta-percha, compared with rotary in-
strument removal . 23 Whenever possible, post space
should be prepared with rubber dam isolation to prevent
bacterial contamination of the root space. If the space
becomes contaminated during post space preparation or
before cementation, an antibacterial solution such as
2.5% sodium hypochlorite can be used to disinfect the
space before treatment continues.
Excessive removal of gutta-percha may contribute
to failure of the root canal treatment (Figure 9-5). A
retrospective study of 200 patients concluded that the
increased apical periodontitis associated with teeth
with posts may result from the loss of the apical seal or
the improper removal of root canal obturating mate-
ria1. 24 Observation of teeth with less than 3 mm of
remaining root filling indicated a statistically signifi-
cant increased frequency of periapical radiolucencies
than teeth where more than 3 mm of root filling re-
mained. 25 An in vitro study by Nixon 26 also demon-
strated that leaving more than 3 mm of filling mate-
rial greatly decreases the level of leakage; 5 mm or
more is optimal. Numerous other authors support
leaving 4 to 5 mm of undisturbed gutta-percha after
post preparation. 1,27-34
Anti-Rotation and Positive Stop
Anti-rotation features are required in all post and core
restorations. Techniques for applying these features in-
clude using pins or keyways or preparing the remaining
coronal tooth structure. In a ribbon-shaped canal anti-
rotation is achieved in the core. The rounder the canal,
the greater the need to provide anti-rotation in the
preparation. 3 A positive stop of the core onto sound
dentin is required to prevent a wedging effect that could
contribute to root fracture.
Ferrule Effect
The ferrule effect is achieved by encircling the remaining
tooth structure with a cast band of metal. This effect has
been shown to significantly increase the fracture resis-
tance of an endodontically treated tooth by counteract-
ing functional stresses such as lever forces and wedging
 Chapter Nine Restoration o f the Endodontically Treated Tooth 13 7

A B

FIGURE 9-4 A, The inadequate length of this post, which was shorter than the crown, may have
contributed to the failure of the restoration. B, The prepared tooth exhibits a lack of ferrule on the
mesial side of the tooth.

FIGURE 9-5 A rotary drill was used instead of a heated instru- FIGURE 9-6 Key features of an endodontically treated incisor
ment to remove gutta-percha. This technique resulted in perfora- restored with a crown include antirotation, ferrule, positive stop,
tion of the root. and a minimum of 5 mm of remaining gutta-percha.

effects (Figure 9-6). 28 Opinions vary regarding the
amount of ferrule needed, 35,36 but 1.5 to 2 mm should
be considered the clinical minimum. 28 Surgical crown
lengthening is often used to increase ferrule. This option
should be considered with caution. Gegauff 37 demon-
strated that decoronated premolar teeth that received
surgical crown lengthening to provide a 2-mm ferrule
were more likely to fracture because of the altered
crown-to-root ratio than teeth receiving no crown
lengthening. Orthodontic extrusion can be used to in-
crease ferrule without compromising the crown-to-root
ratio. 38 Incorporation of a ferrule is perhaps the single
most important factor in maintaining the endodontically
treated tooth restored with a crown.
13 8 Color Atlas of Endodontics
Core Materials
The core should provide an ideal preparation form
for the final restoration. Similar to a preparation in nat-
ural tooth, the core provides retention and a resistance
form for the fabricated crown. A number of direct core
materials are commercially available for use with pre-
fabricated posts. Categories of core materials include
amalgam alloy, reinforced resins, and glass ionomer.
Advantages of alloy include its strength and stability.
However, it requires a bulk of material and therefore is
more frequently applicable to molars and larger pre-
molar teeth. Amalgam demonstrated no microleakage
in a study of various core materials placed under
crowns and should therefore be considered for a core
material whenever the crown margin cannot be ex-
tended more than 1 mm from the core junction. 39 Resin
cores are often placed in anterior teeth because of their
ability to mimic natural tooth color, which can be ad-
vantageous under all-ceramic crowns. This matching
color can be a disadvantage if it makes detecting the lo-
cation of the resin with respect to the crown margin dif-
ficult. An opaque white resin core material precludes a
graying effect and allows detection of its location by
the clinician. In vitro research on glass ionomer has
demonstrated low strength compared with other core
materials. Glass ionomer cements should probably be
reserved for use in very selected anterior and posterior
teeth because of their insufficient adhesion when used
alone with pins or posts and their questionable long-
term fatigability.1
PREPARATION AND FABRICATION
TECHNIQUES
Corono-Radicular Amalgam Foundations
The corono-radicular amalgam foundation, also called
an amalcore or chamber-retained amalgam, is condensed
into the pulp chamber and occasionally the coronal root
canal space to gain retention. It can be used for poste-
rior teeth with adequate coronal structure (two remain-
ing walls) that exhibit undercut chambers large enough
to receive a bulk of amalgam. This foundation can be
placed in one visit and can be as strong as other types of
foundations provided adequate bulk is created . 40,41
Kane 4 2 demonstrated that 4 mm of remaining pulp
chamber height negated the need to place amalgam into
the canals. Amalgam cores placed in the chamber can
easily be removed if retreatment becomes necessary. Re-
moval is more difficult if the amalgam has been placed
into the radicular space.
1. Place a rubber dam if possible.
2. Remove the provisional restoration and all remain-
ing coronal restorative materials, caries, and unsup-
ported tooth structure.
3. Plan for at least a 2-mm thickness of amalgam over
tooth structure that is going to be covered by amalgam.
4. Remaining gutta-percha in the pulp chamber can be
removed with a warmed endodontic plugger.
5. Remove 2 mm of gutta-percha from each root
canal only if this is necessary for additional reten-
tion (i.e., retention in chamber is less than ideal
[4 mm]).
6. Inspect chamber for undercuts, and enhance reten-
tion if necessary by placing additional undercut ar-
eas into the chamber walls. An inverted cone or di-
amond bur is useful for this step.
7. Place a stainless steel or copper matrix band if needed.
An existing provisional crown can be converted to a
matrix by creating a large opening in the occlusal sur-
face through which amalgam can be condensed.
8. Incrementally condense amalgam into the pulp
chamber, then continue to fill the matrix to the level
dictated by remaining tooth structure and predeter-
mined height.
9. Begin to carve the alloy to the appropriate height
while the matrix is in place.
10. Remove the matrix after initial setting has occurred
and carefully check occlusion if the tooth has not al-
ready been prepared for a crown.
11. If the tooth has already been prepared for a crown,
the amalgam may be carved to the contours of the
desired crown preparation. In this situation the clin
ician should select a fast set amalgam alloy that will
allow careful preparation of the core at the same
visit.
12. The final prepared core should be well condensed
and exhibit good retention and resistance form (Fig-
ure 9-7).
13. The clinician must take care when fabricating or re-
lining a provisional crown not to fracture the newly
placed core.
Pre fabricated Posts
The tooth type, root length, and root morphology dic-
tate the type of post to be used. Two basic categories of
prefabricated posts are available: passive and active. Ac-
tive posts primarily gain their retention by threads that
engage the intraradicular tooth structure. Passive posts
gain their retention from the luting agent.
A large number of prefabricated posts are available
in lengths ranging from 8 to 22 mm and diameters rang-
ing from 0.5 to 1.9 mm. A majority of current prefabri-
cated posts are a passive design, are just as likely to be
parallel as tapered, and tend to be made of stainless steel
or titanium. Newer compositions include the carbon fiber
post (C-Post, Bisco Dental Products, Schaumburg, IL).
The manufacturer of the C-post claims that it has the
same elasticity as dentin and prevents the root fractures
associated with cast and prefabricated metallic posts. The
newer zirconium oxide posts (CosmoPost, Ivoclar North
America, Inc., Amherst, NY) are tooth-shaded posts to
 Chapter Nine Restoration o f the Endodontically Treated Tooth
FIGURE 9-7 A, Preparation for an amalcore foundation. B, Restora-
tion with an amalcore foundation.
which a tooth-colored resin or ceramic core may be at-
tached. Zirconium oxide posts are becoming popular be-
cause of the increased use of all-ceramic crowns. They are
advocated for use with the more translucent all-ceramic
crowns (such as IPS Empress) where a metallic post and
core may render a graying effect. 43
Prefabricated post systems often come with cali-
brated drills that correspond to the available diameters;
these allow for ease of final post space shaping and re-
move minimal tooth structure (Figure 9-8). The fol-
l owing method is used for preparation and placement
of a parallel-sided prefabricated post (ParaPost XP,
Coltene/Whaledent, Mahwah, NJ).
13 9
FIGURE 9-8 Preformed post systems usually contain calibrated
drills to assist with post space preparation.
1. Prepare remaining tooth structure. Undercuts do not
need to be removed.
2. Plan for the length and diameter of the post using a
parallel, distortion-free radiograph as a guide.
3. Remove gutta-percha to the planned length desired
for the post using a heated instrument or solvents.
Adequate removal can be confirmed by exposing a
radiograph.
4. Using Gates Glidden drills, enlarge the post space
according to the size ParaPost desired, ending with
the size that corresponds to the size of the planned
ParaPost (Table 9-2).
1 40
*#1 (0.50) and #2 (0.70) drills may be used to enlarge a small canal to accommodate a #3 drill.
5. To parallel the post space, select a ParaPost X drill
that is smaller than the last Gates Glidden drill used
in step 4. Place a rubber stop on the drill to the de-
sired depth or use the drill markings as a guide.
( ParaPost X drills can be used manually with the
Universal Hand Driver or with a slow-speed contra-
angle [750 to 1000 rpm]. A new drill is indicated
when manual drilling is performed.)
' 6. Sequentially step up to the next larger ParaPost X
drill until the predetermined diameter and depth are
achieved.
7. Select the ParaPost XP post that corresponds to the
last drill used to prepare the post space.
8. Before cementing the post, confirm that the length of
the post corresponds to the depth of the newly created
post space. Reinsert the last drill used into the post
space to confirm the depth of the preparation. Place
the post next to the drill so the base of the post head is
slightly above the final depth measurement identified
on the drill. Using a cutting disc, remove the portion of
the post that extends beyond the apical end of the
drill. Re-chamfer the end of the post to its original
shape. A radiograph can be made to confirm complete
seating of the post before cementation.
9. Use a cylindrical diamond or carbide bur to prepare
an anti-rotational box.
0. Place the post into the post space. Check for oc-
clusal clearance. Remove the post and further ad-
j ust the length by trimming the apical end if needed.
Re-chamfer the apical end to its original shape and
debride the post.
11. Air abrade the post with 50 micron aluminum ox-
ide before cementation to enhance micro-mechan-
ical retention
12. Use the dental cement of your choice, according to
the manufacturer's instructions, to cement the post.
Place the cement in the canal with a lentulo spiral.
This results in an even coating of cement. However,
this technique should be avoided when using a ce-
Color Atlas o f Endodontics
ment that sets by oxygen inhibition such as Panavia
21 (Kuraray America, Inc., New York, NY). For
this type of cement, the luting agent should be
placed only on the post.
13. Remove excess cement and fabricate the rest of the
amalgam or composite core. This is most easily
done with the aid of a matrix (Figure 9-9).
Cast Post and Core
The cast post and core has been considered the gold
standard in restoration of the root canal treated tooth
when a post must be placed to retain a core. This is par-
ticularly true for anterior teeth, where occlusal forces are
oblique and not directed along the long axis of the tooth.
Additionally, with a cast post and core the core will not
separate from the post.
Fabrication o f the Direct Cast
Post and Core Pattern
A method for fabricating a custom cast post and core
pattern using the ParaPost casting system is described in
the following Clinical Technique. It allows the creation
of a pattern that has the retentive features of a parallel,
serrated post (apical portion) and the custom fit of a ta-
pered post (coronal portion).
1. Prepare the remaining coronal tooth structure, re-
moving any unsupported or weakened tooth struc-
ture and all previous restorative material.
2. Plan for the diameter and depth of the post using a
radiograph as a guide.
3. Remove gutta-percha to the length desired for the
post using a heated instrument or solvents.
4. Using Gates Glidden drills, enlarge the post space
according to the size ParaPost desired, ending with
the size that corresponds to the size of the planned
ParaPost (see Table 9-2).
 Chapter Nine Restoration o f the Endodontically Treated Tooth 14 1

FIGURE 9-9 Restoration with a prefabricated post and core. A, Endodontically treated incisor with
5 mm of gutta-percha remaining; undercuts may persist. B, Canal space prepared with Gates Glid-
den burs and corresponding ParaPost drills. C, Composite resin build-up of direct core material.
D, Final contour using a diamond bur and high-speed handpiece.

5. To parallel the post space, select the ParaPost X drill
that is smaller than the last Gates Glidden drill used in
step 4. Place a rubber stop at the desired depth or use
the drill markings as a guide. (ParaPost X drills can be
used manually with the Universal Hand Driver or
with a slow-speed contra-angle [750 to 1000 rpm].)
6. Sequentially step up to the next larger ParaPost X
drill until the predetermined diameter and depth are
achieved.
7. Use a cylindrical diamond or carbide bur to prepare
an anti-rotational box without undercuts.
8. Place into the prepared post space a ParaPost XP
burnout post (P-751) that corresponds to the largest
ParaPost X drill used to prepare the post space. If nec-
essary, shorten the post from the apical end.
9. Build up the core pattern with pattern resin, then
shape and finish the coronal mass of resin using
medium and fine diamonds with water spray while
142 Color Atlas o f Endodontics

FIGURE 9-10 Restoration with a cast post and core. A, Endodontically treated incisor with 5 mm
of gutta-percha remaining; undercuts must be removed. B, Canal space prepared with Gates Glid-
den burs and corresponding ParaPost drills. C, The tooth is lubricated and pattern resin is placed us-
i ng a bead-brush technique. D, The coronal portion of the pattern is contoured using a fine diamond
bur and high-speed handpiece with water spray.

holding the pattern firmly in the tooth. ( Lubricate
the tooth with a water-soluble lubricant such as
SurgiLube [Figure 9-10].)
10. Building the pattern should be a two-step process.
Build the internal portion of the pattern first and en-
sure that it can be removed before creating the entire
pattern (Figure 9-11).
11. The finished pattern should be smooth and free
from voids and exhibit good resistance and reten-
tion form (Figure 9-12).
12. Sprue, invest, and cast with Type III dental alloy
( Figure 9-13).
3. Perform try-in and cementation.
14. The post and core restored tooth should exhibit all
the features of an ideal crown preparation (Figure
9-14).
 Chapter Nine Restoration of the Endodontically Treated Tooth 1 43

FIGURE 9-11 The internal portion of the pattern is built and easy FIGURE 9-12 The completed post and core pattern.
removal ensured before the entire core is completed.

FIGURE 9-13 The post and core pattern has been cast with Type III gold and air abraded with 50-
micron aluminum oxide.
1 44 Color Atlas o f Endodontics
FIGURE 9-14 Tooth #5, an abutment for a fixed partial denture, was restored using a cast post and
core. A, Prepared tooth. B, Cemented cast post and core; note the 360° of remaining tooth struc-
ture for ferrule.
Fabrication o f an Indirect Cast
Post and Core Pattern
Follow steps 1 through 7 described previously for fabri-
cation of a direct cast post and core pattern, then per-
form the following steps:
8. Place into the prepared post space the ParaPost XP
impression post (P-743) corresponding to the last
drill used. If necessary, adjust the length of the im-
pression post so the post does not contact the im-
pression tray.
9. Take an impression with an elastomeric impression
material. Make sure the anti-rotational box is filled
with impression material.
10. Pour a model and fabricate a precision removable die.
11. Place the corresponding ParaPost XP burnout post
into the post space of the model.
12. Complete the core pattern and remove it from the
model. The finished pattern should be smooth and
free from voids and exhibit good resistance and re-
tention form.
13. Sprue, invest, and cast with Type III dental alloy.
The Provisional Post Crown
The temporary post crown is a potential weak link in the
restoration of endodontically treated teeth because it
may permit bacteria to enter the radicular space. There-
fore a temporary post crown should be used for as short
a time as possible.' ,' A temporary post crown may be
fabricated from a variety of provisional crown materials
but should always have well-fitting margins to hinder
leakage.
Fabrication o f the Provisional Post Crown
After the custom post and core pattern is made, a provi-
sional post such as the one provided in the ParaPost sys-
tem can be used. This type of post provides good adap-
tation to the prepared canal and prevents leakage. The
steps for fabricating a direct pattern are outlined in the
following Clinical Technique.
1. Lubricate the tooth and adjacent teeth with a water-
soluble lubricant such as SurgiLube.
2. Place a ParaPost XP aluminum temporary post
(P-746) that corresponds with the planned final post
size into the prepared canal space.
3. If a provisional crown was made previously, check
that it fits over the post and seats fully into the
proper occlusion. If it does not seat fully, remove
material from the inside of the provisional crown or
shorten the provisional post at the apical end.
4. Flow provisional crown reline material around the
post, allowing it to fill any existing space.
5. Flow reline material into the provisional crown as
well and seat it onto the post, allowing it to set but
removing it before the final set to prevent it from
locking into adjacent tooth undercuts.
6. When the provisional crown is removed, the post is
incorporated into the internal surface.
7. Trim away excess reline material and evaluate mar-
gins for adequate seal and fit.
8. If discrepancies are evident, reline the margins to
correct them. The finished provisional restoration
should mimic the planned definitive restoration in
contour and fit.
 Chapter Nine Restoration of the Endodontically Treated Tooth
FIGURE 9-15 A, A Micro-Etcher allows air abrasion surface treatment with 50-micron aluminum
oxide. B, The clinician should air abrade the entire surface of the cast post and core before cemen-
tation to increase retention.
9. Cement the provisional post crown with provisional
cement. The use of non-eugenol cement such as
TempBond NE (Kerr USA, Romulus, MI) is recom-
mended because the provisional post crown will
need to be relined after cementation of the cast post
and core. Eugenol has been demonstrated to inhibit
the set of some provisional crown materials. To pre-
serve the integrity of the post space, apply tempo-
rary cement only to the margins of the crown; do
not place any cement into the post space or on the
post.
10. If a provisional crown was not made previously, a
similar technique using some type of matrix such as
a vacuum-formed polystyrene matrix or polyvinyl
siloxane putty matrix may be used to create a crown
form around the post and remaining tooth.
11. A large endodontic file can be substituted for the
provisional ParaPost post.
Post Cementation
Prefabricated posts and custom cast posts may be ce-
mented with a variety of luting agents. Zinc phosphate
has a long history of clinical effectiveness and is still fre-
quently employed. Although it is more time consuming
to mix and proper technique is essential, it has been re-
ported to be least affected by eugenol compared with
other cements. 44 An additional advantage to zinc phos-
phate is the potential for removal of the post with ultra-
sonic instrumentation if the tooth requires retreatment
1 45
or the post fractures. Eugenol has been shown to sig-
nificantly reduce the retention of posts cemented with
some resin cements and recommendations have been
made to irrigate the post space with ethyl alcohol or etch
with 37% phosphoric acid gel to remove the eugenol
residue. 45 Other choices include glass ionomer and com-
posite resin cements. When using glass ionomer, the clin-
ician should consider the capsulated form instead of the
hand-mixed variety. Because of its consistent powder-to-
liquid ratio the capsulated glass ionomer has been shown
to contribute to significantly increased retention com-
pared with the hand-mixed form . 46 Resin ionomer hy-
brid cements should probably be avoided for post ce-
mentation because their tendency to expand may place
undue pressure on the tooth root. One study evaluating
the retention of posts with resin, glass ionomer, and hy-
brid cements revealed disappointing results for the hy-
brids compared with the resin and glass ionomer ce-
ments. 47 Composite and glass ionomer luting agents are
not easily removed when retreatment is required.
To enhance retention, the surface of the post can be
micro-roughened before cementation with 50-micron
aluminum oxide and a micro air abrasive unit (Micro-
Etcher, Danville Engineering Inc., Danville, CA) with 60
p.s.i. air pressure (Figure 9-15). 48 Before cementation of
the definitive crown, the cast custom core may be treated
with the micro abrasive unit intraorally. This removes
residue from the temporary cement and leaves a clean,
micro-roughened surface for final cementation. The
1 46 Color Atlas o f Endodontics
tooth should be irrigated and dried with paper points be-
fore cementation to remove residue from the canal space
preparation. The EndoEze System by Ultradent (South
Jordan, Utah) features small capillary tips that can be at-
tached to high-volume suction to remove irrigant from
the post space efficiently and effectively. This system re-
moves excess moisture but does not desiccate dentin,
which is important particularly when resin cement is
used (Figure 9-16). A single paper point can then be used
to verify the absence of irrigant.
Installation stress during cementation should be min-
i mized. Although tapered posts tend to be self-venting,
placement of a parallel post can generate hydrostatic
backpressure. Venting of the post should be considered
to allow excess cement to escape during the cementation
process, thereby relieving cementation pressure. Some
post systems have vents incorporated into the post de-
sign. Alternatively, a vent may be placed along the side
of the post using a '/ round carbide bur. The clinician
should also consider hydrostatic pressure when select-
ing a cement for the post. A study by Morando et a1 49
examined posts cemented with three different luting
agents: resinous cement, glass ionomer cement, and zinc
phosphate cement. The mean hydrostatic pressures
( p.s.i.) were recorded. Zinc phosphate cement created
substantially greater hydrostatic pressure than either the
resinous or glass ionomer cements. Therefore, venting
may be particularly important during use of zinc phos-
phate cement.
Restoration o f Endodontic Access
through Full-Coverage Crowns
Endodontic treatment occasionally needs to be per-
formed through an existing crown. In this situation, root
canal treatment is more challenging. The restorative den-
FIGURE 9-16 The capillary suction tip in the EndoEze System
allows efficient and effective removal of irrigant from the post
space.
tist must replace tooth structure removed during access
opening and repair the void left in the crown. A decision
must be made regarding whether the crown should be
restored or replaced. Although endodontic access prepa-
ration can decrease retention of a crown, retention can
be regained by subsequent placement of an appropriate
restoration. 50,51 Amalgam is generally used to restore en-
dodontic access through a cast gold crown. The current
trend to place all-ceramic crowns on posterior teeth cre-
ates an esthetic dilemma. If the crown does not fracture
during the access procedure, the patient probably will
not want an alloy in the access cavity. In this situation,
alloy may be still placed in the chamber, much as an
amalcore would be placed. The last 2 mm of coronal
opening is then treated as a porcelain repair. The porce-
lain is etched and receives a silane application, and com-
posite is placed to restore the occlusal surface in a man-
ner that mimics the original ceramic crown material.
With this technique, amalgam provides a coronal seal
over the root canal filling and the patient receives an es-
thetic restoration.
SUMMARY
Endodontically treated teeth do not appear to exhibit
physical and mechanical properties that are significantly
different from those of vital teeth. Loss of coronal struc-
ture is a major concern. Numerous techniques are avail-
able to restore the endodontically treated tooth. A sig-
nificant factor in any technique is incorporation of a 1.5
to 2 mm ferrule. Success does not totally depend on the
technique employed. Numerous factors such as remain-
ing tooth structure, occlusal forces, and the function and
periodontal status of the tooth are important. The clini-
cian must consider all these factors when choosing a
method for restoration.
References
1. Gutman JL, Tidwell E: Restoring endodontically treated teeth,
Texas Dent J 114:14, 1997.
2. Saunders WP, Saunders EM: Corona] leakage as a cause of failure
i n root-canal therapy: a review, Endod Dent Traumatol 10:105,
1994.
3. Bateman LA: Fundamentals o f fixed prosthodontics, Carol Stream,
IL, 1997, Quintessence.
4. Nyman S, Lindhe J: A longitudinal study of combined periodontal
and prosthetic treatment of patients with advanced periodontal
disease, J Periodontol 50:163, 1979.
5. Sorensen JA, Martinoff JT: Endodontically treated teeth as abut-
ments, J Prosthet Dent 53:631, 1985.
6. Hatzikyriakos AH, Reisis Gl, Tsingos N: A 3-year postoperative
clinical evaluation of posts and cores beneath existing crowns, J
Prosthet Dent 67:454, 1992.
7. Papa J, Cain C, Messer HH: Moisture content of vital vs. en-
dodontically treated teeth, Endod Dent Traumatol 10:91, 1994.
8. Huang TJ, Schilder H, Nathanson D: Effects of moisture content
and endodontic treatment on some mechanical properties of hu-
man dentin, J Endod 18:209, 1992.
 Chapter Nine Restoration o f the Endodontically Treated Tooth
9. Reeh ES, Messer HH, Douglas WH: Reduction in tooth stiffness as
a result of endodontic and restorative procedures, J Endod 15:512,
1989.
10. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coro-
nal coverage: a study of endodontically treated teeth, J Prosthet
Dent 51:780, 1984.
11. Lovdahl PE, Nicolls JI: Pin-retained amalgam cores vs. cast-gold
dowel-cores, J Prosthet Dent 38:507, 1977.
12. Goodacre CJ, Spolnik KJ: The prosthodontic management of en-
dodontically treated teeth: a literature review. Part 1. Success and
failure data, treatment concepts, J Prosthod 4:243, 1994.
13. Leary JM, Aquilino SA, Svare CW: An evaluation of post length
within the elastic limits of dentin, J Prosthet Dent 57:277, 1987.
14. Lu YC: A comparative study of fracture resistance of pulpless
teeth, Chin Dent J 6:26, 1987.
15. Guzy GE, Nicholls JI: In-vitro comparison of intact endodonti-
cally treated teeth with and without endo-post reinforcement,
J Prosthet Dent 42:39, 1979.
16. Trope M, Maltz Do, Tronstad L: Resistance to fracture of re-
stored endodontically treated teeth, Endod Dent Traumatol
1:108, 1985.
17. Turner CH: Post-retained crown failure: a survey, Dent Update
9:221, 1982.
18. Newburg RE, Pameijer CH: Retentive properties of post and core
systems, J Prosthet Dent 36:636, 1976.
19. Felton DA et al: Threaded endodontic dowels: effect of post design
on incidence of root fracture, J Prosthet Dent 65:179, 1991.
20. Standlee JP, Caputo AA, Hanson EC: Retention of endodontic
dowels: effects of cement, dowel length, diameter, and design,
J Prosthet Dent 39:401, 1978.
21. Tjan AH, Whang SB: Resistance to root fracture of dowel chan-
nels with various thicknesses of buccal dentin walls, J Prosthet
Dent 53:496, 1985.
22. Trabert KC, Caputo AA, Abou-Ross M: Tooth fracture-a com-
parison of endodontic and restorative treatments, J Endod 4:341,
1978.
23. Haddix JE et al: Post preparation techniques and their effect on
the apical seal, J Prosthet Dent 64:515, 1990.
24. Eckerbom M, Magnusson T, Martinson T: Prevalence of apical
periodontitis, crowned teeth and teeth with posts in a Swedish
population, Endod Dent Traumatol 7:214, 1991.
25. Kvist T, Rodin E, Reit C: The relative frequency of periapical le-
sions in teeth with root canal-retained posts, J Endod 15:578,
1989.
26. Nixon C, Vertucci FJ, Swindle R: The effect of post space prepa-
ration on the apical seal of root canal obturated teeth, Todays
FDA 3:1C, 1991.
27. McClean A: Criteria for the predictably restorable endodontically
treated tooth, J Can Dent Assoc 64:652, 1998.
28. Sorenson JA, Engelman MJ: Ferrule design and fracture resistance
of endodontically treated teeth, J Prosthet Dent 63:529, 1990.
29. Goodacre CJ, Spoolnik KJ: The prosthodontic management of en-
dodontically treated teeth: a literature review. Part II. Maintain-
i ng the apical seal, J Prosthod 4:51, 1995.
1 47
30. Mattison GD et al: Effect of post preparation on the apical seal,
J Prosthet Dent 51:785, 1984.
31. Schnell FJ: Effect of immediate dowel space preparation on the
apical seal of endodontically filled teeth, Oral Surg 45:470, 1978.
32. Madison S, Zakariasen KL: Linear and volumetric analysis of api-
cal leakage in teeth prepared for posts, J Endod 10:422, 1984.
33. Zmener O: Effect of dowel preparation on the apical seal of en-
dodontically treated teeth, J Endod 6:687, 1980.
34. Camp LO, Todd MJ: The effect of dowel preparation on the api-
cal seal of three common obturation techniques, J Prosthet Dent
50:664, 1983.
35. Cohen S, Burns RC: Pathways of the pulp, ed 4, St Louis, 1987,
Mosby.
36. Trabert KC, Cooney JP: The endodontically treated tooth: restora-
tive concepts and techniques, Dent Clin North Am 28:923, 1984.
37. Gagauff AG: Effect of crown lengthening and ferrule placement
on static load failure of cemented cast post-cores and crowns,
J Prosthet Dent 84:169, 2000.
38. Rosenstiel SF, Land MF, Fujimoto J: Contemporary fixed prostho-
dontics, ed 3, St Louis, 2001, Mosby.
39. Tjan AHL, Chin J: Microleakage of core materials for complete
cast gold crowns, J Prosthet Dent 61:659, 1989.
40. Nayyar A, Walton R, Leonard L: An amalgam coronal-radicular
dowel and cone technique for endodontically treated posterior
teeth, J Prosthet Dent 43:511, 1980.
41. Clark J: Clinical dentistry, Philadelphia, 1983, Harper and Row.
42. Kane JJ, Burgess JO, Summitt JB: Fracture resistance of amalgam
coronal-radicular restorations, J Prosthet Dent 63:607, 1990.
43. Kakehashi Y et al: A new all-ceramic post and core system: clini-
cal, technical, and in vitro results, Int J Periodont Restor Dent
18:586, 1998.
44. Dilts WE et al: Effect of zinc oxide eugenol on shear bond
strengths of selected core/cement combinations, J Prosthet Dent
55:206,1986.
45. Tjan AHL, Nemetz H: Effect of eugenol-containing endodontic
sealer on retention of prefabricated posts luted with an adhesive
composite resin cement, Quintessence Int 23:839, 1992.
46. Mitchell CA, Orr JF, Russell MD: Capsulated versus hand-mixed
glass-ionomer luting cements for post retention, J Dent 26:47,
1998.
47. Love RM, Purton DG: Retention of posts with resin, glass
i onomer and hybrid cements, J Dent 26:599, 1998.
48. Williamson RT. Cast core pre-cementation preparation, J Prosthet
Dent 73:320, 1995.
49. Morando G, Leupold RJ, Meiers JC: Measurement of hydrostatic
pressures during simulated post cementation, J Prosthet Dent
74:586, 1995.
50. McMullen AF, Himel VT, Sarkar NK: An in vitro study of the ef-
fect endodontic access preparation has upon the retention of
porcelain fused to metal crowns of maxillary central incisors,
J Endod 15:154, 1989.
51. Yu YC, Abbott PV: The effect of endodontic access cavity prepa-
ration and subsequent restorative procedures on incisor crown re-
tention, Aust Dent J 39:247, 1994.
TEB SINA CHEHR
(4070932 - 6418770)
150 Color Atlas of Endodontics
FIGURE 10-1 Skull specimen demonstrating the maxillary an-
terior osseous structures.
FIGURE 10-2 Skull specimen demonstrating the maxillary pos-
terior region. Note the relationship of the zygomatic process and
the maxillary first and second molars.
alveolar nerve, and mental nerve. In addition, the thick-
ness of bone in the maxillary and mandibular posterior
areas can make access difficult.
Surgical procedures involving the maxillary anterior
teeth are not usually complicated by the proximity of the
roots to vital structures such as nerves and major vessels;
moreover, the facial cortical bone is often thin. Root mor-
phology is not complex because the teeth have only one
canal (Figure 10-1). In the premolar and molar regions,
the root anatomy becomes more complicated and the
bone thickens. The premolars may exhibit one, two, or
three roots that are often divergent. Even teeth with only
one root may have more than one canal. In the posterior
region the zygoma may prevent access to the buccal roots
of the molars (Figure 10-2). This is especially important
in treatment decisions regarding the mesiobuccal root,
which is often broad and has a significant extension to-
ward the palate. Often the roots of the maxillary molars
are in proximity to the sinus. Strategic structures of the
FIGURE 10-3 Palatal view demonstrating the incisive canal and
the greater palatine foramen.
FIGURE 10-4 The mandibular anterior region of the mandible.
Note the labial inclination of the incisors and the tendency for con-
vergence of the roots.
palate include the incisive neural vascular bundle and
greater palatine nerve and vessels (Figure 10-3).
The cortical plate is significantly thicker in the
mandible than it is in the maxilla (Figure 10-4). In the
anterior area the teeth are often inclined facially, with
the roots tipped lingually in the alveolar process. In ad-
dition, the roots tend to converge apically, placing them
in close proximity (see Figure 10-4). Surgery in the
premolar region is complicated by the presence of the
mental foramen and nerve. The root canal anatomy of
these teeth is often complex, with one, two, or three
canals present. In the posterior region the buccal shelf
becomes prominent, increasing the thickness of bone
( Figure 10-5). As the bone thickness increases, access to
the broad buccal-lingual roots of the mandibular molars
becomes more difficult. Moreover, the roots may ap-
proximate the mandibular canal, and flap reflection must
take into consideration the location of the mental fora-
men (see Figures 10-4 and 10-5). Mandibular second
 Chapter Ten Endodontic Surgery 151

FIGURE 10-5 A mandible demonstrating the external oblique

ridge and the mental foramen. Note the way the thickness of the
osseous tissues on the buccal aspect increases in the second and
third molar region.

Modified from Johnson WT et al: Measurement of blood flow to osseous tissue in

dogs using the radiolabeled microsphere method, Comp Biochern Physiol
106A:649,1993.
*SEM, Standard error of mean.

Knowledge of the microvasculature permits the place-

ment of vertical releasing incisions that do not compro-
mise blood supply to the reflected tissue and that de-
crease bleeding by running parallel with the vessels.
Blood flow to the anterior and posterior maxilla and
anterior mandible does not appear to have significant
differences; however, blood flow to the posterior man-
dible is less than that to the other structures. 9

ARMAMENTARIUM
Surgical treatment requires a unique set of instruments
and materials (Figures 10-6 through 10-13). The basic
Modified from Squier CA, Nanny D: Measurement of blood flow in the oral mucosa
and skin of rhesus monkey using radiolabeled microspheres, Arch Oral Biol 30:313,
tray set-up is as follows:
1985.
*SEM, Standard error of mean. Mouth mirror
Explorer
molars are closest to the mandibular canal, followed by Periodontal probe
the second premolars. The mesial root of the mandibular Millimeter ruler
first molar is farthest from the canal. The path of the Cotton tip applicators
mandibular canal follows an S-shaped curve in one third Gauze
of the cases: lying buccal to the distal root of the second Cotton forceps
molar, crossing to the lingual below the mesial root of Surgical blades and handle
the second molar, and then running lingual to the first Spoon excavator
molar before crossing back to the buccal apical to the Periosteal elevators
second premolar.5 Surgical suction tip and stylet
Oral tissues are highly vascularized and have signifi- Hemostat
cantly greater blood flow than skin tissues (Tables 10-1 Micro amalgam carrier
and 10-2). 6-9 Within the oral tissues, high blood flow is Condenser and carver
correlated with the thickness of the epithelium.$ The pri- Aspirating syringe, needle, and anesthetic
mary blood supply for the gingival tissues comes from Irrigating syringe bowl and sterile saline
vertically oriented vessels in the alveolar mucosa.10, 11 Needle holder
152 Color Atlas o f Endodontics

FIGURE 10-b A conventional high-speed handpiece and a slow- FIGURE 10-7 Ultrasonic tips.
speed microsurgical handpiece.

FIGURE 10-8 A conventional mouth mirror and various micro- FIGURE 10-9 Microsurgical blades.
surgical mirrors.

FIGURE 10-10 A Stropko irrigating device (EIE/Analytic Tech- FIGURE 10-11 A Messing gun (Produits Dentaires, S.A., Vevey,
nology, San Diego, CA). Switzerland).
 Chapter Ten Endodontic Surgery 15 3

FIGURE 10-12 Mineral trioxide aggregate (ProRoot) and Super FIGURE 10-13 Various hemostatic agents (bone wax, CollaTape [In-
EBA cement. tegra Life Sciences, Plainsboro, NJ], Nugauze [Johnson & Johnson
Medical, Inc., Arlington, TX], Astringident [Ultradent Products, Inc.,
South Jordan, UT], Hemodent [Stone Pharmaceuticals, Philadelphia,
PA], calcium sulfate [Surgi Plaster, Class Implant SRL, Rome, Italy]).

Scissors vasoconstrictors is essential in the highly vascularized

Suture material oral tissues, and the duration of action of the anesthetic
solution is important for pain control. To maximize the
The following instruments are recommended: benefits of these agents, the clinician's initial injections
should include a long-acting local anesthetic agent such
Minnesota retractor as bupivacaine or etidocaine. Long-acting anesthetic
Messing gun (Produits Dentaires, S.A., Vevey, agents provide profound anesthesia for 2 to 4 hours and
Switzerland) analgesia for as long as 10 hours.
Root tip elevators The best method of controlling hemorrhage is to es-
Ultrasonic unit and surgical tips tablish hemostasis before flap reflection. This is accom-
Microsurgical blades plished by injecting lidocaine with 1:50,000 epinephrine
Microsurgical mirrors at various sites in the alveolar mucosa and near the root
Stropko irrigator (EIE/Analytic Technology, San end. The slow injection of the solution in numerous sites
Diego, CA) within the localized operative field should be accom-
Air impact handpiece (45 degrees) plished even with block anesthesia because the localized
Microsurgical scissors effect of the vasoconstrictor is more pronounced. Epi-
Surgical operating microscope nephrine that is administered slowly poses little risk to the
patient and provides effective hemostasis.l2 Infiltration
i nto the loose alveolar connective tissue produces pre-
ANESTHESIA
dominantly vasoconstriction because of the action of epi-
Local anesthesia is important in surgical procedures for nephrine on the alpha-1 receptors associated with vessels
pain control and hemostasis. The hemostatic action of of the microvasculature. The clinician should exercise care
154 Color Atlas of Endodontics
FIGURE 10-14 I nitial incisions for a full-thickness mucoperiosteal
flap for surgical treatment of the maxillary left first premolar. Note the
i nitial oblique incision that preserves the papilla.
FIGURE 10-16 A diagrammatic representation of a triangular intrasulcular flap with an anterior re-
l easing incision.
during the injection to avoid delivering the anesthetic into
muscles, where beta-2 receptors are located. This action
results in vasodilation and increases bleeding. In posterior
periodontal surgery, 1:50,000 epinephrine significantly re-
duced blood loss compared with 1:100,000 epinephrine. 13
FLAP DESIGN
General principles of flap design include the following:
1. The flap should provide for adequate access and
vision.
2. The flap design should provide for adequate
blood supply to the reflected tissues.
3. The flap design should provide for soft tissue clo-
sure over solid bone.
4. The flap used in periapical surgery should involve
reflection of both mucosa and periosteum.
FIGURE 10-15 Tissue reflection involves an undermining tech-
nique initiated from the vertical releasing incision. The elevator is
used laterally to lift the periosteum and associated tissues from
the alveolar process. This prevents crushing of the crestal bone.
Additional considerations in flap design choice in-
clude the importance of locating incisions away from
anatomic structures, awareness of any pathologic defects,
and evaluation of the projected bony window. The in-
tegrity of the papilla should be maintained (Figure
10-14), reflection of the soft tissues should be performed
with an undermining technique (Figure 10-15), sharp an-
gles should be avoided, and the flap should permit passive
tissue retraction. Horizontal incisions in the attached gin-
giva and alveolar mucosa may result in scar formation.
Most endodontic surgical procedures require a re-
flection of a full-thickness mucoperiosteal flap. The in-
trasulcular and submarginal flaps are each described by
the location of the horizontal incision. Vertical releas-
i ng incisions can be used with either intrasulcular or
submarginal flaps. These incisions can be made one or
two teeth proximal to the tooth being treated and can
be placed both mesial and distal to the operative site.
 Chapter Ten
FIGURE 10-17 A diagrammatic representation of a submarginal
flap.
Flaps are described by their shape (triangular or rectan-
gular). Triangular flaps are often employed in anterior
areas, whereas the rectangular shape is more common in
posterior areas. When a rectangular flap is used, the
base should be as wide as the coronal portion of the re-
flected tissue to ensure an adequate blood supply to the
reflected tissue. Vertical incisions should be made be-
tween the root eminences and parallel to the vascula-
ture and the collagen fibers present in the tissue. This
reduces hemorrhage, enhances healing, and discourages
scar formation.
Intrasulcular Flap
The intrasulcular flap (Figure 10-16) involves an inci-
sion in the gingival sulcus. Advantages to the intrasul-
cular flap include good access and visibility. Because the
supraperiosteal vessels are not cut and remain in the re-
flected tissue, bleeding is controlled and the reflected
papilla provides a reference for closure. A disadvantage
of this flap design is the potential for recession. 14 This
disadvantage becomes crucial when esthetic restora-
tions are present. To reduce the possibility of recession,
the operative area should be free of inflammation and
abnormal probing depths. The connective and epithe-
lial tissues remaining on the root and cortical bone
must be kept vital.15 Incisions should sever the peri-
odontal ligament fibers to the crestal bone, and the
papillae should be incised in the midcol area because
collateral circulation from the lingual aspect appears to
be limited. The tissue should be reflected with an un-
dermining technique initiated from the vertical releas-
ing incision. 1 6 Working an elevator laterally, the clini-
cian frees the periosteum and associated tissues from
the alveolar process apical to the attached gingiva (see
Figure 10-15). The intact attached marginal gingiva is
then lifted from around the teeth. This undermining
methodology minimizes damage to periodontal fibers
Endodontic Surgery 15 5
FIGURE 10-18 A diagrammatic representation of the seldom-
used semilunar flap.
by eliminating direct crushing pressure of the elevator
on the attachment apparatus and crestal bone. In the
presence of healthy tissues and careful tissue manage-
ment, the intrasulcular flap can be used without pro-
ducing recession.15
Submarginal Flap
The submarginal flap (Figure 10-17) entails a scalloped
horizontal incision placed in attached gingiva at least 2
mm apical to the attachment. 17 The main advantages
with this flap are that the marginal gingiva and crestal
bone are not disturbed. The submarginal incision allows
both access and visibility. Disadvantages include the sev-
ering of vessels providing blood supply to the crestal tis-
sues, as well as the lack of reference for closure. The hor-
izontal incision also cuts across the collagen fibers,
resulting in shrinkage and scar formation." Contrain-
dications to this flap include limited attached gingiva,
periodontal defects in the operative site, short roots, and
large periradicular lesions if the horizontal incision is
made over the osseous defect.
Semilunar Flap
A third flap, the semilunar flap (Figure 10-18), is rarely
used in contemporary root end surgery. With this flap a
horizontal incision is made in the alveolar mucosa over
the root to be treated. Although this flap does not dis-
turb the periodontal attachment, it has the disadvantages
of limited access and visibility, encroachment on and clo-
sure over osseous defects, increased potential for hemor-
rhage, and healing with scar formation.
Regardless of the flap selected for a surgical pro-
cedure, ensuring the health of the operative site is an
important consideration. The use of 0.12% chlorhex-
idine as a presurgical mouth rinse can decrease the bac-
terial count and enhance the response to treatment.
Patients should use the rinse the day before surgery,
 15 6 Color Atlas o f Endodontics

A B

C D

FIGURE 10-19 A, A clinical photograph of a 36-year-old woman with an expansive lesion in the
anterior mandible. B, An occlusal radiograph revealing a radiolucent area in the mandible with as-
sociated tooth displacement. C, Aspiration of the lesion. 0, Flap reflection reveals a soft tissue lesion
that has eroded the buccal cortical plate. Histopathologic examination revealed the lesion to be a
central giant cell granuloma.

i mmediately preceding surgery, and for the week after
surgery. 1 9
Before performing initial flap resection, the clini-
cian can employ an aspiration technique as a diagnos-
tic procedure. Aspiration is performed by inserting a
19-gauge needle into the lesion. Aspiration of signifi-
cant amounts of blood may indicate a vascular lesion,
aspiration of straw-colored fluid may indicate a cyst,
and a nonproductive aspiration may indicate a neo-
plasm (Figure 10-19).
ROOT END RESECTION AND ROOT
END FILLING
Before performing root end resection, the operator must
have adequate access to the root end (Figures 10-20
through 10-22). After initial flap reflection the facial or
buccal cortical plate should be inspected for perforation
by the lesion. Often this inspection aids in locating the
root end. The perforation may be small and appear sim-
ilar to the surrounding bone. Tactile and close visual in-
spection should be performed to determine the presence
of any defects. When a defect in the bone is noted, the
clinician expands the area using a rotary bur in a high-
speed handpiece. Light, intermittent pressure and a wa-
ter coolant is essential to reduce frictional heat. If no per-
foration is noted, the clinician can estimate length by
subtracting several millimeters from the length of the
tooth on a distortion-free parallel preoperative radio-
graph. Accurate length estimation ensures that the oper-
ator will contact the root and not remove excessive
amounts of bone apical to the root end. In areas with
strategic anatomic structures, preparation of the osseous
window should begin at mid-root and be carried api-
cally. Because bone and root tissues appear similar, iden-
tification of the root may be difficult if no lesion is pres-
ent. The yellow color of dentin and the presence of a
bleeding periodontal ligament between bone and dentin
are two clinical clues that distinguish root from bone.
Application of methylene blue to the osseous crypt pref-
erentially stains the periodontal ligament. On occasion,
bone removal may occur without root visualization. In
FIGURE 10-20 A, A clinical photograph of a 24-year-old female patient with a history of pulp
necrosis of her maxillary central incisors after traumatic injury. Root canal treatment was performed
on the maxillary left central incisor, resulting in an overfill. Root end resection was performed by an
oral surgeon who failed to place a root end filling. The tooth has remained sensitive to biting pres-
sure. B, A preoperative radiograph demonstrates previous root canal treatment and root end resec-
tion. C, A submarginal flap was used to gain access to the root end. D, Root end preparation was ac-
complished using an ultrasonic handpiece and tip. E, A root end filling was placed. F, Postoperative
radiograph of the completed root end filling. G, Healing at 2 days after surgery.
FIGURE 10-21 For legend, see opposite page.
 Chapter Ten Endodontic Surgery 15 9

FIGURE 10-21 A, A clinical photograph of a 34-year-old man with swelling in the buccal furcation
area of his mandibular right first molar, tooth #30. He gives a history of previous root canal treatment
with silver cones that required retreatment. B, A preoperative radiograph. Note the metallic-appearing
material in the mesial root and associated radiolucent area. C and D, After root resection, inspection
of the root and root tip is important. Note the accessory canals associated with the root tip. E, A clin-
i cal photograph taken after root end resection and filling. Note the perpendicular resection as well as
the pathologic defect. F, A radiograph of the completed root end filling demonstrates inclusion of the
i sthmus. G and H, A 1-year recall photograph and radiograph demonstrate resolution of the lesion and
osseous regeneration.

FIGURE 10-22 A, Preoperative clinical photograph of a draining sinus tract opposite the maxillary
right second premolar, tooth #4, 6 months after retreatment. The adjacent teeth were responsive to
pulp testing with C02 . B, Preoperative radiograph demonstrates a periradicular radiolucent area.
C, A clinical photograph of the resected root end demonstrates placement of a root end filling con-
sisting of Super EBA cement. D, A postoperative radiograph.
160 Color Atlas of Endodontics
these situations the clinician may place a small, sterile,
radiopaque object in the area and expose a radiograph.
Awareness of radiographic relationships and knowledge
of the orientation of the osseous window and root end
assist in location of the appropriate root apex.
After obtaining access, the clinician curettes the le-
sion and collects a specimen for histopathologic exami-
nation. Although complete removal of the lesion is ideal,
it is not essential as long as the etiology for the lesion
can be identified and eliminated. This concept is impor-
tant when lesions extend to adjacent teeth and complete
removal may compromise the blood supply to these teeth
or other vital structure s.20,21
Periradicular curettage is followed by inspection of
the root for lateral and accessory canals, overextension
of the obturating materials, vertical root fractures, and
variations in tooth anatomy and morphology. This in-
spection is facilitated by the use of a surgical operating
microscope. Root resection is accomplished by section-
ing the apical 2 to 3 mm or by gradually shaving the root
end to the desired length. Although an ideal resection
should be perpendicular to the canal, resection may be
oblique because placement of a bevel facilitates access
for root end preparation. Root end resection removes the
area where accessory canals are most likely to occur,
provides a surface area for root end preparation, and
promotes visualization of the entire periphery of the
root. In general, the greater the root resection, the more
surface area is available for root end preparation. A
common error in root end resection is the failure to cut
completely through the root. Because roots frequently
exhibit a lingual orientation (maxillary lateral incisors,
mesiobuccal roots of maxillary molars, mandibular an-
terior teeth), an oblique resection may fail to remove the
root end. In addition, bevels expose more dentinal
tubules on the root surface compared with perpendicular
resections. The resected portion and the root surface
should be inspected after completion of root resection . 22
In addition, the portion of the root that is removed
should also be examined. When viewing the root end,
the clinician should be able to visualize and follow the
periodontal ligament circumferentially. The root should
be inspected for fractures and anatomic variations such
as the presence of an isthmus. Irrigation with sterile
saline and application of methylene blue dye can assist
this process. Trans illumination is also an effective
method of inspecting the root end. Visualization of the
resected root end is best accomplished with a surgical
operating microscope. 23
After preparing the osseous window and resecting the
root, the clinician should prepare the root end to receive
an apical filling. Because visual inspection cannot con-
firm an apical seal, a root end filling should be placed
where possible to ensure that the seal is adequate . 23
Historically the root end was prepared with a micro-
handpiece or a small bur in a high-speed handpiece (see
Figure 10-6). Preparations were often round and large
and seldom parallel with the canal. The recent introduc-
tion of ultrasonic tips permits root end preparations that
mimic the shape of the canal (see Figures 10-7 and
10-20). These instruments exhibit a variety of tip designs,
are small, and permit greater access in difficult locations.
Tips with a zirconium nitride coating are also available.
Ultrasonic preparations are parallel, can be extended to
the recommended 3-mm depth, can include anatomic
variations such as the isthmus between two canals in a
single root, and are generally cleaner because of the irri-
gation used with the system . 23,24 Because an isthmus may
not be visually detectable, roots with two canals should
be prepared as though an isthmus is present. 23
Root end preparation using ultrasonic instrumenta-
tion has been shown to produce preparations that are
cleaner, smaller, deeper, and more parallel; they also ac-
curately follow the root canal space . 25-31 An additional
advantage to the use of ultrasonics is the decreased bevel
required to perform the preparation. Evidence suggests
that more leakage occurs with a beveled root compared
with a perpendicular root end resection. 25,32
A disadvantage to ultrasonic preparation is the po-
tential for cracks and chipping. Although the production
of cracks is controversial, the power setting used and the
remaining thickness of dentin may be significant factors
in their etiology.33-35
Regardless of the risks, ultrasonic root end prepara-
tion has a higher clinical success rate than use of the
micro-handpiece.36 An alternative to ultrasonic prepara-
tion is preparation with a sonic handpiece and diamond
coated retro-tips. The success rate of this technique ap-
pears similar to that seen with ultrasonics. 37
On completion of root end preparation the osseous
crypt should be irrigated with sterile saline, dried, and
inspected. The depth of the preparation should be as-
sessed to ensure that it extends 3 mm into the root and
follows the long axis of the root. The preparation should
extend apical to the facial or buccal level of the resected
surface.
Control of hemorrhage and management of the os-
seous crypt are essential components of placing a root end
filling.38-40 Hemostasis can be achieved in a number of
ways (see Figure 10-13). The use of epinephrine-
impregnated pellets has been advocated . 41 After removing
the granulomatous tissue from the osseous site, the clini-
cian places an epinephrine-impregnated pellet, as well as
several sterile cotton pellets. Pressure is applied for several
minutes. The sterile cotton pellets are then removed, leav-
ing the epinephrine pellet in place. The vasoconstriction
produced by this technique is synergistic with the applica-
tion of pressure. Racemic epinephrine pellets are available
commercially as Racellets (Pascal Co, Bellevue, WA). The
#2 size pellet averages 1.15 mg of epinephrine, whereas
the #3 pellets average 0.55 mg of epinephrine. Although
the pellets are effective, their fibers may remain in the sur-
 Chapter Ten
gical site. Impeccable technique and thorough attention to
removal should eliminate foreign body responses and heal-
ing impairment.
Ferric sulfate is an effective solution for hemostasis.
Coagulation occurs rapidly after direct application to the
osseous tissue. The solution is caustic and can be placed
on a cotton pellet or Telfa pad for application to the
crypt. Use of the solution should be limited to the crypt.
After the procedure the coagulated material should be
curetted from the osseous site.42 Viscostat (Ultradent
Products, Inc., South Jordan, Utah) is a commercially
available ferric sulfate solution that is somewhat viscous.
Additional materials that can be used to control hem-
orrhage include CollaTape and CollaCote (Integra Life
Sciences, Plainsboro, NJ), as well as Avitene (Davol, Inc.,
Cranston, RI). These microcrystalline collagen sub-
stances are biocompatible, trigger platelet aggregation,
and activate the intrinsic clotting pathway. After their
application, the osseous defect can be packed with cot-
ton pellets, Telfa pads, Gelfoam (Pharmacia and Upjohn
Company, Kalamazoo, MI), or Surgicel (Johnson &
Johnson, Somerville, NJ). Although it is understood that
cotton pellets and Telfa pads must be removed, Gelfoam
and Surgicel also must be removed because they retard
healing. 43
Bone wax has been advocated as a mechanical he-
mostatic agent in periapical surgery. 44 The material is
packed to fill the entire osseous defect. Excess material is
then removed to expose the root end. After placing the
root end filling, the clinician must remove the bone wax.
Evidence indicates that inadequate material removal can
elicit a foreign body reaction . 4 3
Calcium sulfate is a biodegradable agent that may be
used as a hemostatic agent. As with bone wax it me-
chanically plugs the vascular channels. Long used as a
bone void filler in orthopedic surgery, the material is
mixed to a putty-like consistency and placed in the bony
crypt. Pressure is applied with a wet cotton pellet. The
material is biocompatible and resorbs over time.
One factor that has been promoted to enhance heal-
ing involves demineralization of the resected root end be-
fore root end filling. Citric acid burnished on resected
surfaces removes the smear layer, exposes collagen, and
enhances cementogenesis. 45 Discussion remains regard-
ing the advantages of using this technique. No signifi-
cant improvement in long-term success rates may occur
using this or other demineralization agents.
Root end filling can be accomplished after establish-
ment of a dry operating field. Materials that are accept-
able include amalgam, Diaket, super ethoxybenzoic acid
(Super EBA), Intermediate Restorative Material (IRM),
and Mineral Trioxide Aggregate (Pro Root MTA,
Dentsply/Tulsa Dental, Tulsa, OK) .46-51 Although con-
troversy regarding the use of amalgam has existed for
many years because of concerns about toxicity, leakage,
and long-term success, the majority of studies indicating
Endodontic Surgery 161
poor long-term success were done before the advent of
new technologies that have improved visualization, crypt
management, and root end preparation techniques . 50
These significant variables may have a greater effect on
successful treatment than the material used as the root
end filling. Currently amalgam is being replaced with al-
ternative materials. Super EBA and IRM are similar in
that both are zinc oxide and eugenol materials, Super
EBA having less eugenol. Super EBA consists of a pow-
der composed of zinc oxide, silicone dioxide, and a resin
and a liquid made up of ethoxybenzoic acid and eugenol.
Both materials appear to have higher clinical success
rates than amalgam . 48 Mineral trioxide aggregate is a
new material that has been advocated as a root end fill-
ing material. The principal components of MTA are tri-
calcium silicate, dicalcium silicate, bismuth oxide, trical-
cium aluminate, tetracalcium aluminoferrite, and cal-
cium sulfate dehydrate. Advantages include a superior
seal compared with Super EBA, low toxicity, and healing
of the periapical tissues with cementum forming over the
material.51
Regardless of the material chosen for the root end
filling, the field should be dry. The material is placed in
the preparation and condensed. Because preparations
with ultrasonic instrumentation are considerably smaller
than those required with traditional methods, smaller
condensers are required to compact the material. The
preparation is overfilled and, as in the use of amalgam,
the excess is removed. Super EBA and IRM should be al-
lowed to set before finishing. When setting is complete,
the excess can be removed and the material smoothed
with a carbide finishing bur. MTA does not adhere well
and sets slowly, so after placement a damp cotton pel-
let can be used to remove the excess and clean the root
surface.
After placement of the root end filling, an interim ra-
diograph or radiographs should be exposed to ensure
that the root tip has been totally removed, no excess ma-
terial is present in the osseous crypt, and the placement
of the root end filling is adequate . 5 2
The osseous defect can be irrigated with sterile saline
and the tissues re-approximated after an interim radio-
graph has been exposed. Blood loss during apical surgery
is minimal . 53 Closure is accomplished in most cases with
placement of interrupted sutures. Continuous, vertical
mattress, and sling suturing techniques are also used. Su-
turing is performed by engaging the reflected flap and
suturing it to the attached mucosa. The size and type of
sutures are variable. Diameters range from 3-0 to 8-0.
Nonabsorbable silk or absorbable collagen-derived mate-
rials such as gut and chromic gut are commonly employed.
Synthetic absorbable materials containing polyglycolic
acid and polyglactin have also been developed. After su-
turing the flap should be compressed with digital pressure
and a moist gauze for 5 to 10 minutes. This decreases the
thickness of the coagulum and enhances healing. 54
16 2 Color Atlas o f Endodontics

Recently the use of guided tissue regeneration tech-

niques has been advocated in periapical surgery where
large lesions are present.'-' Large lesions appear to heal
quicker and with a higher quality and quantity of bone
when a membrane is placed before closure. The routine
use of guided tissue regeneration in periradicular surgery A
remains controversial. The technique adds cost to the
procedure and may not improve results in treatment of
lesions of average size.56
Postoperative instructions should be given to the pa-
tient orally and in writing. The patient should be advised
to apply an ice pack extraorally the day of surgery. Ice
should be placed intermittently, 10 minutes on and 10
minutes off. A soft diet is recommended and hot liquids
are to be avoided. The patient should be advised to limit
physical activity for the rest of the day. The patient B
should be informed that oozing may occur for the first
24 hours and that some swelling and tissue discoloration
is possible. The majority of patients exhibit very little
discomfort after the procedure." Ibuprofen, acetylsali-
cylic acid, and acetaminophen are effective in control-
ling pain in most patients. Narcotic analgesics can be
considered if over-the-counter remedies are ineffective.
Antibiotic therapy is not indicated unless signs and
symptoms consistent with systemic infection occur or the
patient's medical status dictates antibiotic use. In addi-
tion, oral hygiene instructions should be given. Gener- C
ally patients are instructed to brush and floss their teeth
as they normally would, except at the surgical site. The
patient is instructed to rinse the surgical site with warm
salt water three or four times a day, beginning the day
after surgery. If the patient was placed on a chlorhexi-
dine rinse before surgery, this should be continued. Su- FIGURE 10-23 A, A preoperative radiograph revealing extensive
tures are removed after 3 or 4 days. recurrent caries on the distal of the mandibular right first molar,
Recent advances in surgical techniques and mate- tooth #30. B, Radiograph taken after endodontic treatment demon-
rials have improved the success rates for root end sur- strates removal of the distal root and restoration with a proprietary
gery. 36,37,58,59 Factors that influence the success rate post, amalgam core, and full gold crown. C, A clinical photograph of
i nclude improved visualization, enhanced methods of the completed case.
hemorrhage control, ultrasonic preparation techniques,
and the use of new root end filling materials. Because
many of these techniques and materials are incorporated
in various combinations in patient treatment procedures,
identification of which factor or factors is most signifi- Root amputation can be considered if severe isolated
cant is impossible. bone loss occurs around an individual root; if caries, re-
sorption, or vertical root fracture make a root nonre-
storable; if endodontic treatment cannot be performed;
ROOT AMPUTATION AND HEMISECTION or if perforation occurs during endodontic treatment
Root Amputation ( Figure 10-23). Contraindications to root removal in-
Root amputation is a procedure designed to remove an clude fused roots, roots that are in close proximity, in-
entire root of a multirooted tooth while leaving the ability to perform endodontic treatment on the retained
crown intact. Hemisection is a term frequently applied segment, inability to restore or clean the retained seg-
to the removal of one root of a mandibular molar. In this ment, and poor oral hygiene. "Restorability" of the re-
procedure both the root and associated portion of the tained segment, maintenance of biologic width, and
crown are removed. Bicuspidization is a term that ap- strict home care are crucial considerations often over-
plies to the surgical separation of the roots of a mandibu- looked in the treatment planning process. Removal of a
lar molar without removal of the roots. Each root is then root requires an interdisciplinary approach with en-
restored with a separate crown. dodontic, periodontic, and restorative components.
 Chapter Ten Endodontic Surgery 1 63

ANATOMIC CONSIDERATIONS. The anatomy and mor-

phology of the tooth have significant implications for re-
storability, periodontal maintenance, and prognosis dur-
ing treatment planning. The shape of the retained root
may be difficult to restore and for the patient to maintain
adequate oral hygiene.

MAXILLARY MOLARS. In maxillary molars the

mesiobuccal root generally curves distally, is broad in the
buccal lingual dimension with the furcation toward
the lingual, and exhibits mesial and distal concavities.
The root alignment is similar to that of the maxillary
premolars, and the root exhibits a large surface area for
support. In cross-section the root may have an hourglass
appearance. This may complicate the restorative plan
and make oral hygiene difficult. In addition, the presence
of one or two small canals makes post placement diffi-
cult. The distobuccal root is relatively straight, but may
exhibit an apical curvature. The root is round in cross-
section. The palatal root is the most divergent, extending
lingually in relationship to the crown. The root is wider
in the mesiodistal dimension than it is buccolingually.

MANDIBULAR MOLARS. In mandibular molars the

mesial root curves toward the distal, is wider in its buc-
colingual dimension than in its mesiodistal dimension,
and exhibits the greatest surface area. The root has con-
cavities on both the mesial and distal surfaces, giving the
root an hourglass configuration in cross-section. The dis-
tal root is also wider in its buccolingual dimension than
in its mesiodistal dimension. A concavity on the mesial
surface gives the root a kidney bean configuration in
cross-section.

Root Resection
When feasible, endodontic treatment should precede
root removal. This permits adequate isolation for clean-
ing and shaping, assessment of the remaining tooth
structure, and placement of a definitive restorative ma-
terial in the coronal portion of the root to be resected. In
addition, the tooth can be evaluated for occlusal inter-
ferences and a plan can be developed for provisional sta-
bilization. To provide access and visibility and maintain
adequate biologic width, flap reflection and osseous re-
contouring should be performed in conjunction with the
root resection procedure.
Two primary methods are used for root removal (Fig-
ure 10-24): the horizontal cut and the vertical cut. A
third, less popular, method involves presurgical crown
contouring. The initial cut should be made in a manner
that sacrifices tooth structure from the root to be re-
moved while maintaining as much structure as possible
on the segment to be retained. The retained segment FIGURE 10-24 A, A diagrammatic sketch of a mandibular first
can always be recontoured. After making the initial cut, molar exhibiting periodontal bone loss involving the mesial root.
the clinician should verify complete separation of the B, A horizontal root resection that maintains the crown. C, A verti-
root before placing an elevator between the two seg- cal resection removing the mesial root and associated portion of
ments and gently moving the two pieces apart. The root the crown.
16 4 Color Atlas o f Endodontics

FIGURE 10-25 A, A clinical photograph of a mandibular first molar with a history of previous root
canal treatment, retreatment, and restoration with an amalgam core and crown. Note the buccal
area of inflammation. B, A preoperative radiograph displays radiolucent areas associated with the
mesial and distal roots. C, Intentional replantation was selected as the treatment of choice because
of the thickness of the buccal cortical bone. Root end resection was accomplished using a high-
speed handpiece and water coolant. Root end fillings were placed in each root. D, A postoperative
radiograph of the tooth. Note that the crown was dislodged during extraction. E, A 3-year recall ra-
diograph. A deep mesial-buccal periodontal pocket was evident clinically. F, Examination on extrac-
tion revealed a vertical root fracture and external apical resorption. G and H, Scanning electron mi-
croscopic examination of the apical resorption.
 Chapter Ten
should move independent of the crown. The area is irri-
gated and inspected after root removal to ensure the ab-
sence of overhangs or sharp edges and establish that the
area is cleanable. Both the tooth and bone can be shaped
to provide a cleanable area. Regardless of the technique
employed, the clinician must exercise care to ensure that
no overhanging tooth structure is left in the furcation
and that 3 mm of circumferential tooth structure re-
mains coronal to the osseous crest.
Success rates for root resection are 60% to 70%.60-62
Failures tend to occur for a variety of reasons after ex-
tended periods of time. Root resection is a predictable
treatment option that may offer the opportunity to
maintain a portion of a strategic tooth . 63
I NTENTIONAL REPLANTATION
Intentional replantation is a procedure that offers the
clinician the opportunity to maintain a tooth that can-
not be managed nonsurgically. It can also be used in
cases where root end surgery is not a viable option (Fig-
ure 10-25). Although intentional replantation is a treat-
ment alternative, it should be used as a last resort be-
cause extraction of the tooth may lead to fracture, which
renders replantation impossible. Success rates vary from
70% to 80%, with case selection being crucial . 64,65 Teeth
with flared roots may fracture during extraction and
must be evaluated closely when they are being consid-
ered for this type of procedure.
The success of intentional replantation primarily de-
pends on the amount of time the tooth is out of the
socket. Another factor is management of the root sur-
face. After atraumatic extraction the periodontal tissue
on the root or roots should be maintained in a moist en-
vironment. This can be accomplished by holding the
tooth by the crown in a gauze soaked in physiologic
saline or Hank's balanced salt solution. The root is kept
moist with frequent saline irrigation.
If endodontic treatment is possible, the clinician
should clean, shape, and fill the canal or canals and re-
store access before extraction and replantation. In cases
where previous endodontic treatment has been under-
taken or where the canals are calcified, the root end
should be resected, a root end preparation performed,
and a root end filling placed extraorally.
Immediately before replantation the socket should be
irrigated with saline to remove the clot. The tooth is then
replanted and stabilized if necessary. In posterior areas,
splinting is often not necessary. If a tooth requires stabi-
lization, an acid-etch physiologic splint or sutures can be
used.
Success depends on precise and efficient performance
of the procedure. Damage to the root surface during ex-
traction and the length of time the tooth is out of the
socket affect the prognosis. Maintaining the viability of
the periodontal membrane reduces the incidence of re-
placement resorption and enhances healing.
Endodontic Surgery 1 65
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13. Buckley JA, Ciancio SG, McMullen JA: Efficacy of epinephrine
concentration on local anesthesia during periodontal surgery, J
Periodontol 55:653, 1984.
14. Grung B: Healing of gingival mucoperiosteal flaps after marginal
incision in apicoectomy procedures, Int J Oral Surg 2:20, 1973.
15. Harrison JW, Jurosky KA: Wound healing in the tissues of the
periodontium following periradicular surgery. 1. The incisional
wound, J Endodon 17:425, 1991.
16. Gutmann JL, Harrison JW: Posterior endodontic surgery: anatom-
ical considerations and clinical techniques, Int Endod J 18:8,
1985.
17. Lang NP, Loe H: The relationship between the width of kera-
tinized gingiva and gingival health, J Periodontol 43:623, 1972.
18. Kamper BJ, Kaminski EJ, Osetek EM: A comparative study of the
wound healing of three types of flap design used in periradicular
surgery, J Endodon 10:17, 1984.
19. Sanz M et al: Clinical enhancement of post-periodontal surgical
therapy by a 0.12% chlorhexidine gluconate mouthrinse, J Peri-
odontoL 60:570, 1989.
20. Soulti A, Torbinejad M: Histologic study of healing periradicular
lesions with and without curettage, J Endodon 20:188, 1994.
21. Lin LM, Gaengler P, Langeland K: Periradicular curettage, Int En-
dod J 29:220, 1996.
22. Rud J, Andreasen JO: Operative procedures in periapical surgery
with contemporaneous root filling, Int J Oral Surg 1:297, 1972.
23. Rubenstein R: The anatomy of the surgical operating microscope
and operating positions, Dent Clin North Am 41:391, 1997.
24. Carr GB: Ultrasonic root end preparations, Dent Clin North Am
41:541, 1997.
25. Gagliani M, Taschieri S, Molinari R: Ultrasonic root-end prepa-
ration: influence of cutting angle on the apical seal, J Endodon
24:626, 1998.
26. Hsu Y, Kim S: The resected root surface. The issue of canal isth-
muses, Dent Clin North Am 41:529, 1997.
27. Gutmann JL et al: Ultrasonic root-end preparation. Part 1. SEM
analysis, Int Endod J 27:318, 1994.
1 66 Color Atlas of Endodontics
28. Gorman MC, Steiman HR, Gartner AH: Scanning electron micro-
scopic evaluation of root-end preparations, J Endodon 21:113, 1995.
29. Engel TK, Steiman HR: Preliminary investigation of ultrasonic
root end preparation, J Endodon 21:443, 1995.
30. Lin CP et al: The quality of ultrasonic root-end preparation: a
quantitative study, J Endodon 24:666, 1998.
31. Mehlhaff DS, Marshall JG, Baumgartner JC: Comparison of ul-
trasonic and high-speed-bur root-end preparations using bilater-
ally matched teeth, J Endodon 23:448, 1997.
32. Saunders WP, Saunders EM, Gutrmann JL: Ultrasonic root-end
preparation. Part 2. Microleakage of EBA root end fillings, Int En-
dod J 27:325, 1994.
33. von Arx T, Walker WA: Microsurgical instruments for root-end
cavity preparation following apicoectomy: a literature review, En-
dod Dent Traumatol 16:47, 2000.
34. Layton CA et al: Evaluation of cracks associated with ultrasonic
root-end preparation, J Endodon 22:157, 1996.
35. Abedi HR et al: Effects of ultrasonic root end cavity preparation
on the root apex, Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 80:207, 1995.
36. Bader G, Lejeune S: Prospective study of two retrograde en-
dodontic apical preparations with and without the use of CO2
laser, Endod Dent Traumatol 14:75, 1998.
37. von Arx T, Kurt B: Root-end cavity preparation after apicoectomy
using a new type sonic and diamond-surfaced retrotip: a 1 year
follow-up study, J Oral Maxillo fac Surg 57:656, 1999.
38. Withespoon DE, Gutmann JL: Haemostasis in periradicular
surgery, Int Endod J 29:135, 1996.
39. Sauveur G et al: The control of haemorrhage at the operative site
during periradicular surgery, Int Endod J 32:225, 1999.
40. Kim S, Rethnam S: Hemostasis in endodontic microsurgery, Dent
Clin North Am 41:499, 1997.
41. Besner E: Systemic effects of racemic epinephrine when applied to
the bone cavity during periapical surgery, Va Dent J 49:9, 1972.
42. Jeansonne BG, Boggs WS, Lemon RR: Ferric sulfate hemostasis:
effect on osseous wound healing. II. With curettage and irrigation,
J Endodon 19:174, 1993.
43. Ibarrola JL et al: Osseous reactions to three hemostatic agents, J
Endodon 11:75, 1985.
44. Selden HS: Bone wax as an effective hemostat in periapical
surgery, Oral Surg Oral Med Oral Pathol Oral Radiol Endod
29:262, 1970.
45. Craig K, Harrison JW: Wound healing following demineralization
of resected root ends in periradicular surgery, J Endodon 19:339,
1993.
46. Pantschev A, Carlsson AP, Andersson L: Retrograde root filling
with EBA cement or amalgam. A comparative clinical study, Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 78:101, 1994.
47. Williams SS, Gutmann JL: Periradicular healing in response to
Diaket root-end filling material with and without tricalcium phos-
phate, Int Endod J 29:84, 1996.
48. Dorn SO, Gartner AH: Retrograde filling materials a retrospective
success-failure study of amalgam, EBA IRM, J Endodon 16:391,
1990.
49. Torabinejad M, Chivian N: Clinical applications of mineral triox-
i de aggregate, J Endodon 25:197, 1999.
50. Frank AL, Glick DH, Patterson SS: Long-term evaluation of sur-
gically placed amalgam fillings, J Endodon 18:391, 1992.
51. Torabinejad M et al: Histologic assessment of mineral trioxide ag-
gregate as a root-end filling in monkeys, J Endodon 23:225, 1997.
52. Saad AY, Clem WH: The use of radiographs in periapical surgery,
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 69:361,
1990.
53. Selim HA, El Deeb ME, Messer HH: Blood loss during endodon-
tic surgery, Endod Dent Traumatol 3:33, 1987.
54. Harrison JW Jurosky KA: Wound healing in the tissues of the
periodontium following periradicular surgery. 2. The dissectional
wound, J Endodon 17:544, 1991.
55. Pecora G et al: The guided tissue regeneration principle in en-
dodontic surgery: one-year postoperative results of large periapical
lesions, Int Endod J 28:41, 1995.
56. Bohning BP, Davenport WD, Jeansonne BG: The effect of guided
tissue regeneration on the healing of osseous defects in rat calvaria,
J Endodon 25:81, 1999.
57. Seymour RA, Meechan JG, Blair GS: Postoperative pain after api-
coectomy. A clinical investigation, Int Endod J 19:242, 1986.
58. Sumi Y et al: Ultrasonic root-end preparation: clinical and radio-
graphic evaluation of results, J Oral Maxillo fac Surg 54:590,
1996.
59. Rubenstein RA, Kim S: Short-term observation of the results of
endodontic surgery with the use of a surgical operation micro-
scope and Super-EBA as a root end filling material, J Endodon
25:43,1999.
60. Langer B, Stein SD, Wagenberg B: An evaluation of root resec-
tions: a ten year study, J Periodontol 52:719, 1981.
61. Expenstein H: 3-year study of hemisectioned molars, J Clin Peri-
odontol 10:1, 1983.
62. Buhler H: Evaluation of root resected teeth, results after 10 years,
J Periodontol 59:805, 1988.
63. Buhler H: Survival rates of hemisected teeth; an attempt to com-
pare them with survival rates of alloplastic implants, J Perio Rest
Dent 14:537, 1994.
64. Bender IB, Rossman LE: Intentional replantation of endodonti-
cally treated teeth, Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 76:623, 1993.
65. Ragboebar GM, Vissink A: Results of intentional replantation of
molars, J Oral Maxillofac Surg 57:240, 1999.
TEB SINA CHEHR
(4070932 - 6418770)
16 8 Color Atlas o f Endodontics
FIGURE 11-1 Detection of a horizontal root fracture may require increasing or decreasing the ver-
tical angulation of the beam.
RADIOGRAPHIC EXAMINATION
Radiographs taken after traumatic injury may reveal
tooth displacement, root fractures, osseous fractures,
and foreign objects present in soft tissues. In cases of sus-
pected root fractures, films exposed from several verti-
cal angles may be required to reveal the fracture line9
(Figure 11-1). In lacerated areas a film of the soft tissues
may reveal an embedded object. 10 Radiographs are also
helpful in assessing the degree of apical root develop-
ment in teeth exhibiting crown fractures. A pantomo-
graph may be indicated in cases of suspected osseous
fractures.
DOCUMENTATION
Documentation of findings from the history, clinical ex-
amination, and radiographic examination is important
for an accurate diagnosis, justification of treatment, fu-
ture diagnostic considerations, insurance issues, and de-
fense against potential litigation.11
CROWN FRACTURES
Uncomplicated Fractures
Infraction is a term used to designate an incomplete frac-
ture in enamel without loss of structure (see Figure 11-4,
A). Enamel infractions result from direct impact, are best
visualized with transillumination, and may be the only
visible evidence that trauma has occurred.
Crown fractures result from a high-velocity impact.
Fracture of the crown dissipates the force and mini-
mizes injury to the supporting periodontal structures
and bone. Coronal fractures can involve enamel or
enamel and dentin. The primary symptom associated
with fractures involving enamel and dentin is thermal
sensitivity. Although a fracture involving enamel often
appears insignificant and can be managed by selective
grinding or placement of an acid-etched composite
restoration, the potential for pulpal damage exists. Pulp
testing should be performed to assess vitality. The most
severe pulp response is often seen in teeth exhibiting lit-
tle or no physical damage. 12 In general, however, the
pulpal prognosis for uncomplicated fractures of enamel
and dentin is favorable.13,14
Crown fractures involving both enamel and dentin
expose dentinal tubules to saliva and bacteria (Figure
11-2). The treatment of choice involves placing a pro
tective base and an acid-etch composite restoration. Re-
cent advances in enamel-dentin bonding have enhanced
the bonding of fractured segments.15 In cases with ex-
tensive damage, laminate veneers, porcelain-fused-to-
metal crowns, or all-ceramic crowns may be required to
restore form, function, and esthetics. With coronal frac-
tures of enamel or enamel and dentin, recall evaluation is
required to assess pulp vitality.
Complicated Crown Fractures
Fractures of enamel and dentin have the potential for
pulp exposure. When a coronal fracture is complicated
by pulp exposure in young patients, the extent of apical
development must be determined. Teeth with incomplete
root formation require apexogenesis for continued root
development. Teeth that become nonvital before com-
plete root formation require apexification.
Crown fractures that expose the dental pulp exhibit
the best prognosis when treated immediately. The longer
the pulp is exposed, the greater the bacterial contamina-
tion. This is especially important in teeth with incom-
plete apical development where maintaining vitality is
 Chapter Eleven Traumatic Injuries to the Permanent Dentition 169

FIGURE 11-2 A, An uncomplicated crown fracture involving enamel and dentin. The patient was
asymptomatic with the exception of sensitivity to cold. B, A periapical radiograph demonstrates the
normal periradicular structures. C, Treatment consisted of placing a Class IV acid-etch composite
restoration.

essential for continued root formation. If necrosis oc-
curs, root development may cease.
APEXOGENESIS. Treatment procedures for teeth with
exposed pulp include pulp capping, pulpotomy (Figure
11-3), and root canal treatment (Figure 11-4). Pulp cap-
ping is indicated for teeth with small exposures that can
be treated soon after the injury. Capping can be accom-
plished with calcium hydroxide or a new material, min-
eral trioxide aggregate (MTA). Pulpotomy is indicated
for more severe fractures or teeth in which treatment is
delayed. Removal of several millimeters of pulp tissue
provides space for placement of calcium hydroxide or
MTA and is adequate to remove superficial inflamed tis-
sue in cases where treatment is delayed. Removal of
coronal pulp tissue is best accomplished with an abra-
sive diamond in a high-speed handpiece using a water
coolant. 16 The amputation site should be clean of debris
and tissue tags. Bleeding can be controlled with the ap-
plication of a cotton pellet soaked with sterile saline. If
calcium hydroxide is used, a glass ionomer or interme-
diate restorative material (IRM) base can be placed be-
fore restoration with composite resin. If MTA is used,
the material should set for 1 week before the permanent
restoration is placed. 17 An acid-etch composite restora-
tion is placed to provide a coronal seal and restore es-
thetics and function.
With both pulp capping and pulpotomy, treatment
consists of debridement of the wound and placement of
calcium hydroxide or MTA. Although calcium hydroxide
has been shown to be clinically effective over time, it pro-
duces a superficial layer of coagulation necrosis. The
low-grade irritation of this layer induces the formation
of a hard tissue barrier.18 MTA, however, has been shown
to induce a hard tissue barrier without inflammation. 19
The time interval between exposure and treatment
does not appear to be a significant factor affecting prog-
nosis as long as the coronal inflamed tissue can be re-
moved. Success rates for pulp capping and pulpotomy
procedures after traumatic injury are high . 20 This is
probably because of the acute nature of the injury and
minimal bacterial contamination.
Recall evaluation should be performed after pulp
capping and pulpotomy to assess the patient's response
to treatment. Evaluation is often based on clinical and
radiographic findings because pulp testing may not pro-
duce accurate information. In cases where root develop-
ment is incomplete, verification of continued growth is
evidence of successful treatment. Clinical studies indicate
that successful pulpotomy procedures correlate with nor-
mal histopathologic findings in the pulp tissue . 20 Re-
moval of the pulp after complete root development is
contraindicated unless a post is required for coronal
restoration. In cases where root development is complete
and extensive coronal destruction has occurred, nonsur-
gical root canal treatment can be performed to facilitate
placement of a post, core, and crown.
APEXIFICATION. In cases where necrosis occurs before
complete root formation, apexification procedures are in-
dicated to establish an apical barrier before obturation of
the canal space with gutta-percha (Figure 11-5). In these
1 70 Color Atlas of Endodontics

FIGURE 11-3 A and B, A complicated crown fracture involving the maxillary left central incisor of
an 8-year-old child. C, A periapical radiograph revealed incomplete root formation. D, Postoperative
fil m after a calcium hydroxide pulpotomy and placement of a stainless steel crown. E, A 2-year re-
call film demonstrates complete root formation. Note the dentin bridge that has formed coronally.
F, A clinical view of the dentin bridge. G, Postoperative film taken after nonsurgical root canal treat-
ment to facilitate placement of a post and core.
 Chapter Eleven Traumatic Injuries to the Permanent Dentition 171

FIGURE 11-4 A, A complicated root fracture with pulp exposure involving the maxillary right cen-
tral incisor, tooth #8. Note the crown infraction associated with tooth #9. B, The radiographic exam-
i nation reveals normal periradicular structures and complete apical development. C, Treatment con-
sisted of placing an acid-etch composite as a provisional restoration and nonsurgical root canal
treatment. Definitive treatment consisting of placement of a cast post and core was delayed until or-
thodontic treatment could be provided.

cases the clinician debrides the necrotic tissue remnants
from the canal walls using traditional endodontic proce-
dures. The canal is then packed with calcium hydroxide
powder or a proprietary paste, which is left in place for 2
to 3 months. The location of the barrier depends on the
level at which the calcium hydroxide contacts vital tissue,
so it is important to place the material to the apex.
During the recall examination the calcium hydroxide
is removed and the apical area is assessed radiographi-
cally and clinically for the development of a barrier. If no
barrier is present, the procedure is repeated. The average
time for barrier development is 6 to 12 months.21, 22 The
success rates for apexification are high .21-23
CROWN ROOT FRACTURES
Crown root fractures involve enamel, dentin, and ce-
mentum and account for 5% of all injuries involving the
permanent dentition. 24 Because the fracture extends onto
the root, esthetics and restorability are concerns in
treatment planning (Figure 11-6). The fractures gener-
ally are oblique and extend into the gingival sulcus on
either the buccal or lingual surface. Forces impacting on
the tooth from a facial direction result in fractures that
extend onto the lingual tooth surface. Forces from a lin-
gual direction result in fractures that extend onto the fa-
cial surface of the tooth. Clinically the fractured segment
is often held in place by the periodontal attachment ap-
paratus. Symptoms are related to movement of the frac-
tured segment. The fractures can be uncomplicated or
complicated depending on whether the pulp is exposed.
To assess restorability, the clinician must remove the
fractured segment. Radiographic evidence regarding the
extent of the fracture is often inconclusive.
Treatment options include crown lengthening and or-
thodontic extrusion to reestablish the biologic width in
1 72 Color Atlas o f Endodontics

FIGURE 11-5 A, A clinical photograph of a patient with a history of a trauma (coronal fracture) to
the maxillary left central incisor. The patient developed an apical abscess secondary to pulp necro-
sis while undergoing orthodontic treatment. B, A periapical radiograph demonstrating incomplete
root development. Note the difference in canal size and root formation between #8 and #9. C, Al-
though the radiolucent area appears to involve the maxillary left lateral incisor, this tooth was re-
sponsive to pulp testing. D, After initiating root canal treatment, the clinician packed the canal with
dry calcium hydroxide powder. E, A calcific bridge could be detected with a file at the 3-month re-
call examination. F, Postoperative radiograph demonstrating apical bridge formation and osseous
regeneration. G, A clinical photograph after treatment.
 Chapter Eleven Traumatic Injuries to the Permanent Dentition 1 73

C, D E

FIGURE 11-6 A and B, Clinical photographs of a maxillary right lateral incisor exhibiting a crown
root fracture. C, Radiographic examination reveals normal structures, and the fracture is not appar-
ent. D and E, Removal of the fractured segment permits evaluation of the tooth for restorability.

conjunction with required endodontic and restorative
procedures; extraction also may be cons idered. 25,26 Be-
cause most of these fractures involve anterior teeth, es-
thetics is a major concern. Extrusion may result in a
tooth that exhibits a smaller mesial-distal dimension and
decreased crown-root ratio. Crown lengthening results
in elongation of the tooth with diminished bone support.
An alternative treatment technique is surgical extru-
sion. 27 This technique is only appropriate for teeth with
complete apical development. After administering local
anesthesia, the clinician gently luxates the apical seg-
ment, moves it in a coronal direction, and stabilizes it
with sutures or a splint. Root canal treatment can be per-
formed after initial healing takes place, and restorative
treatment can begin within 6 to 8 weeks after periodon-
tal healing.
ROOT FRACTURES
Horizontal root fractures frequently occur as the result of
facial trauma to the anterior teeth (Figure 11-7). They are
frequently oblique and therefore often difficult to detect.
Clinical features that suggest root fracture are tenderness
to percussion and palpation, tooth mobility, displacement,
and bleeding from the gingival sulcus. Teeth with root
fractures often do not respond to pulp testing. Recent ev-
idence suggests that a negative initial response is signifi-
cantly related to later pulp necrosis.28 Several radiographic
projections may be required to identify the fracture line
( see Figure 11-1). 29 If the initial parallel film does not
demonstrate a fracture, occlusal films may be required.
Variation of the vertical angle may also be useful.
The pulp of the majority of teeth with intact root struc-
ture remains vital. Treatment procedures are designed to
enhance the healing of osseous and supporting periodontal
structures. Four types of healing responses have been de-
scribed for root fractures30:
1. Calcific healing with callus formation between the
closely approximated segments (Figure 11-8)
2. Connective tissue healing whereby the segments are
separated by a fibrous attachment (see Figure 11-7)
3. A combination of bone and connective tissue heal-
ing in which bone grows between the segments
1 74 Color Atlas of Endodontics

FIGURE 11-7 A, Clinical photograph of a patient who fell while playing tennis. Note the hemor-
rhage from the gingival sulcus of the maxillary left central incisor. B, A parallel periapical radiograph
demonstrates a horizontal root fracture C, The fracture is less apparent on a maxillary occlusal film.
D, A postoperative photograph of a rigid wire and composite splint. E, Postoperative film taken af-
ter splint placement. F, A photograph of the dentition after splint removal. G, On recall examination
the tooth was responsive and exhibited normal mobility. Note that during the recall interval, tooth #8
required endodontic treatment because of pulp necrosis.
FIGURE 11-8 A, A radiograph of a patient who related having his maxillary right central incisor frac-
tured in World War II. B, Healing of the fracture site was noted on extraction. C, Note the resorptive le-
sion on the external surface of the root below the fracture site. D, A vertical section reveals the resorp-
tive lesion to be internal and demonstrates destruction of the facial canal wall. As the resorption
progressed, external perforation occurred. E, Scanning electron microscopy of the resorptive defect.
176 Color Atlas of Endodontics

and periodontal ligament formation occurs be-
tween the osseous tissues and the root segments
( Figure 11-9)
4. Nonunion, with granulation tissue formation at
the fracture site resulting from necrosis of the
coronal pulp tissue, which initiates an inflamma-
tory reaction at the fracture line (Figure 11-10);
the inflammation then spreads laterally into the
alveolar bone, inducing resorption and formation
of a "butterfly" radiolucent area
Treatment procedures for teeth exhibiting root frac-
ture should enhance the potential for union of the frac-
tured segments. In cases of root fracture in which
no displacement has occurred and the tooth exhibits
normal mobility, treatment may not be required. In

FIGURE 11-9 Fracture healing with connective tissue and bone.

FIGURE 11-10 A, A periapical radiograph depicting horizontal root fractures of the maxillary cen-
tral incisors. The left maxillary central incisor became necrotic and was opened for drainage. The
maxillary right central incisor is responsive to pulp testing. B, The coronal segment was treated and
the apical segment, which exhibited resorption, was surgically removed. C, A recall radiograph exhibits
osseous regeneration. The maxillary right central incisor remains responsive to testing.
 Chapter Eleven Traumatic Injuries to the Permanent Dentition
cases where the tooth exhibits displacement or mobility,
the clinician should reduce the fracture immediately
and place a rigid splint to immobilize the segments. Ra-
diographic verification of the tooth position after
splinting should be obtained.
Fractures that have a vertical component or extend
near the gingival sulcus have a poor prognosis because of
bacterial contamination from the oral environment and
subsequent periodontal breakdown. Options for treatment
of these teeth include removal of the coronal segment and
crown lengthening, orthodontic extrusion, and extraction.
The splint should remain in place for 8 to 12 weeks
to permit the calcified tissues to heal. The clinical recall
evaluations should assess the pulpal status, tooth mobil-
ity, and periodontal probing depths. A lack of response
to pulp testing does not indicate that necrosis has oc-
curred as long as no other signs or symptoms are associ-
ated with the tooth. The pulp remains vital in the ma-
j ority of cases.31 Signs of necrosis include discoloration,
sensitivity to percussion and palpation, and radiographic
evidence of resorption or a radiolucent lesion. When
necrosis occurs it generally affects only the coronal seg-
ment, with the apical segment remaining vital. 32 Mobil-
ity after 8 to 12 weeks of splinting may require contin-
ued splinting.
If pulp necrosis develops, the coronal segment can be
treated with nonsurgical endodontic techniques as long
as no radiolucent area is associated with the apical seg-
ment, the apical segment exhibits hemorrhage, and an
adequate constricted area is available in the coronal seg-
ment for instrumentation and obturation with gutta-per-
cha (see Figure 11-10). If the apical segment exhibits
signs of necrosis, both segments can be treated nonsur-
gically or the coronal segment can be treated and the api-
cal segment removed surgically (see Figure 11-10). If a
constriction cannot be detected or created, apexification
of the coronal segment is indicated before obturation.
A common finding on recall examination of teeth with
root fractures is canal obliteration and discoloration re-
sulting from calcification. The majority of teeth with canal
obliteration do not become necrotic.33 Endodontic treat-
ment of teeth exhibiting calcification is not warranted un-
less evidence of necrosis exists.
LUXATION INJURIES
Concussion
Concussion is defined as traumatic injury to a tooth that
does not result in mobility or displacement from the
socket (Figure 11-11). The primary clinical finding is
tenderness to biting pressure and percussion resulting
from injury to the supporting structures. An additional
clinical finding is discoloration, although this is not com-
mon. Pulp testing may reveal responsiveness, but the
pulp also may not be responsive to initial testing. Radi-
ographic findings reveal normal structures.
1 77
Treatment is generally palliative. Recall examination
is essential to assess pulpal status. If a tooth that is ini-
tially responsive becomes unresponsive over time, necro-
sis has most likely occurred. A tooth that is initially un-
responsive can become responsive after the injury,
indicating a positive pulpal response . 34 Of the luxation
injuries, concussion has the best pulpal prognosis, with
only 3 % becoming necrotic. 35
Subluxation
Subluxation is defined as a tooth that is slightly mobile
after a traumatic episode but not displaced from the
socket (Figure 11-12). On clinical examination, bleeding
from the gingival sulcus may be observed and the tooth
may be unresponsive to pulp testing. Radiography may
reveal widening of the periodontal ligament.
Treatment is palliative, although the mobility may re-
quire splinting. Because the injury is primarily to the at-
tachment apparatus, a physiologic splint of monofila
ment fishing line and composite resin should be placed
for 7 to 14 days when needed.
Recall examination is performed to assess pulpal sta-
tus. Pulpal necrosis occurs in approximately 6% of all
cases. 35
Lateral and Extrusive Luxation
Lateral and extrusive luxation is a traumatic injury that
results in a tooth being displaced from its socket (Figure
11-13). Because the tooth is moved from the socket, frac-
ture of the alveolar process is a common finding. Often nu-
merous teeth are involved. Pulp testing is unreliable. Dis-
placement disrupts the vascular and neural elements,
frequently resulting in pulp necrosis. Occlusal radiographs
are often valuable in demonstrating tooth displacement. 9
Teeth that are displaced without damage to the
socket can be repositioned and stabilized with a phys-
iologic splint consisting of monofilament fishing line
or orthodontic wire and composite for a period of 7 to
14 days. If a fracture of the alveolar process has oc-
curred, the tooth should be repositioned and a rigid
splint placed for 4 to 6 weeks. Because the incidence
of pulp necrosis is high and often remains undetected,
root canal treatment should be initiated after initial
stabilization.35,36
Intrusive Luxation
The intruded tooth is displaced centrally into bone (Fig-
ure 11-14). Clinical examination reveals a short clinical
crown with gingival hemorrhage. Because the tooth is
displaced into the bone, mobility is absent. Radiographic
examination demonstrates the tooth position. Because of
the crushing injury, the periodontal ligament space may
not be evident. Treatment of teeth that are intruded de-
pends on the extent of apical development. In cases
where root formation is incomplete, the teeth may re-
erupt. If the roots are completely formed, the clinician
178 Color Atlas o f Endodontics

FIGURE 11-11 A, A photograph of a patient who sustained a concussion-type injury. Note the
hemorrhage into the dentin. B, A periapical radiograph reveals horizontal bone loss consistent with
previous periodontal disease and normal apical structures. C, Clinical photograph taken after non-
surgical root canal treatment and internal bleaching. D, A postoperative radiograph.
 Chapter Eleven Traumatic Injuries to the Permanent Dentition 179

FIGURE 11-13 A, A preoperative radiograph of a maxillary right lateral incisor after a lateral ex-
trusive luxation injury. B, A recall radiograph taken after endodontic treatment and orthodontic repo-
sitioning. Note the calcification present in the maxillary central incisors. C, Clinical examination re-
veals normal tissues and tooth coloration.
18 0 Color Atlas of Endodontics

B C

FIGURE 11-14 A, A clinical photograph of a lateral intrusive traumatic injury to the maxillary left
canine. B, A preoperative radiograph demonstrates a widened mesial periodontal ligament space.
C, A postoperative radiograph taken after endodontic treatment.

must reposition the tooth surgically with forceps or
through orthodontic movement. If surgical repositioning
is performed, the tooth should be splinted. Orthodontic
treatment is recommended because it produces decreased
resorption and preserves the crestal bone. 38 Orthodon-
tic treatment should be initiated promptly because the
development of replacement resorption or ankylosis may
prevent tooth movement.
Root canal treatment should also be initiated because
of the poor pulpal prognosis with this type of injury. 15,17
Although the placement of calcium hydroxide is recom-
mended to prevent root resorption, it should take place
only after initial healing is complete because calcium hy-
droxide has been shown to increase resorption when
placed immediately after injury. 39
AVULSION
Avulsion is defined as complete displacement of a tooth
from the socket (Figure 11-15). Although time is of the
essence in treating an avulsed tooth, obtaining a complete
medical and dental history and performing a clinical and
radiographic examination are essential. Treatment pro-
cedures are directed toward management of the pulp and
the more significant periodontal reactions to injury.
Periodontal Reactions to Avulsion
After replantation a coagulum forms between the root
and alveolar bone. After 1 week the epithelial attach-
ment is reestablished at the cementoenamel junction and
the gingival collagen fibers become spliced. 40 This limits
bacterial invasion and permits healing to continue. Four
 Chapter Eleven Tramnatic Injuries to the Permanent Dentition 181

FIGURE 11-15 A, A photograph of a patient who avulsed his maxillary right lateral and both cen-
tral incisors while playing baseball. B, A preoperative radiograph demonstrating complete avulsion
with intact socket walls. C, A photograph of the teeth after replantation. D, An orthodontic appliance
and wire splint in place. E, Splint removal after the initiation of nonsurgical root canal treatment at
2 weeks. F, Calcium hydroxide placement.
18 2 Color Atlas o f Endodontics

FIGURE 11-16 A, A clinical photograph of a maxillary left central incisor that was previously
avulsed. B, A radiograph of the involved tooth demonstrating replacement resorption.

FIGURE 11-17 A, A radiograph of a mandibular left central incisor with a history of lateral luxa-
tion and a lateral incisor that was avulsed and demonstrates inflammatory resorption. B, Clinical view
of a sinus tract that developed as a result of pulp necrosis.
 Chapter Eleven Traumatic Injuries to the Permanent Dentition 18 3

C D

FIGURE 11-17, cont'd C, A postoperative radiograph taken after nonsurgical treatment of the
central and lateral incisors and surgical removal of the apex of the lateral incisor. D, A 6-month re-
call radiograph demonstrates osseous regeneration.

types of periodontal healing have been described .41 The
first is healing with a normal periodontal ligament. Clin-
ically the tooth exhibits a normal position and mobility.
Radiographically the periodontal ligament space is
evident and displays no signs of bone or root resorption.
The second type of healing has been described as healing
with surface resorption. Histologically this response is
characterized by localized areas of superficial resorption
that are repaired by the deposition of new cementum.
The resorptive process is self-limiting, and clinically the
tooth is normal. The resorptive defects are usually not
evident radiographically. The third type of periodontal
response is described as healing with ankylosis or re-
placement resorption (Figure 11-16). This type of re-
sorption is related to loss of vitality of the periodontal
ligament on the root surface. 42 It can be transient with
minimal damage or progressive with extensive damage.
It is characterized by osteoclastic activity and resorption
of the root followed by deposition of bone into the de-
fect. Clinically the tooth is immobile and percussion
elicits a clearly different sound compared with normal
teeth. The radiographic appearance is consistent with the
replacement of root structure by bone and the loss of a
visible periodontal membrane. No known treatment is
available for replacement resorption. The fourth type of
periodontal response is healing with inflammatory re-
sorption (Figure 11-17). Resorptive areas in both the
root and adjacent alveolar bone characterize this
process. Inflammatory resorption occurs when the ex-
ternal resorption of cementum and dentin exposes the
dentinal tubules. Necrotic tissue elements from the pulp,
as well as bacteria and their by-products, penetrate to
the tubules to induce an inflammatory reaction in the
periodontal tissues .43 Clinical evaluation may detect
signs and symptoms of inflammation, infection, and mo-
bility. Radiography reveals radiolucent areas in the root
and adjacent bone. Endodontic treatment may arrest in-
flammatory resorption.
Pulpal Reaction to Avulsion
With mature apical development the pulpal reaction is
necrosis resulting from the severed vascular elements. In
teeth with incomplete apical development the reaction is
also necrotic, although revascularization is possible if the
tooth is replanted within 3 hours (Figure 11-18). 44
Treatment o f Avulsion
Factors affecting the prognosis after replantation include
time out of the socket, treatment of the root surface, the
storage or transport medium, splinting, and endodontic
treatment. Of these factors, the time out of the socket is
the most important. The incidence of replacement re-
sorption increases with the extraoral time interval before
replantation because of loss of viability of the periodon-
tal ligament cells on the root. Teeth replanted within 30
minutes of avulsion exhibit the best prognosis. 45 For this
184 Color Atlas o f Endodontics

FIGURE 11-18 A, A maxillary left central incisor with incomplete root formation that was avulsed
1 month previously and replanted immediately by the patient's mother. B, A 6-month recall ra-
diograph reveals continued root formation. Clinical testing elicited a slow response to cold but none
to electric pulp testing (EPT). C, An 18-month recall radiograph reveals calcific metamorphosis and
nearly complete root formation. The tooth remained responsive to cold but not to EPT. D, A 30-month
recall radiograph reveals complete root formation, apical closure, and continuing calcification. The
tooth exhibited a slight yellowish discoloration and was responsive to EPT but not to cold. (A and D
from Johnson WT, Goodrich JL, James GA: Replantation of teeth with immature root development, Oral
Surg Oral Med Oral Path Oral Radiol Endod 60:420, 1985.)
 Chapter Eleven Traumatic Injuries to the Permanent Dentition
FIGURE 11-19 The Save-A-Tooth emergency tooth-preserving system is sold through Life-Assist,
I nc., in Rancho Cordova, CA.
reason, immediate replantation by the patient or parent
is recommended.
Treatment of the root surface is a factor that affects
healing. The root should not be scraped or scrubbed . 46 If
debris is present on the tooth, it should be gently removed
with saline solution, milk, saliva, or Hank's balanced salt
solution. Tap water is to be avoided whenever possible.
If a tooth cannot be replanted immediately, it should
be placed in an appropriate storage medium for trans-
portation to a dental setting. Air drying is to be avoided
and storage in tap water is damaging to the cellular
elements because of differences in osmolarity. 47,48 Main-
taining viability of the periodontal ligament cells is crucial
because loss of these cells leads to replacement resorp-
tion. Saliva, milk, saline solution, Hank's balanced salt
solution, and Viaspan (Barr Laboratories, Inc., Pomona,
NY) are acceptable storage media. 49-52 Milk has the ad-
vantages of being readily available and acceptable for 6
hours of extraoral storage. Saliva is also readily available,
but it is effective for only 2 hours. The superiority of milk
may be related to osmolarity, nutritional factors, and bac-
teria present. Hank's balanced salt solution has been used
to maintain tissue cultures. It has been shown to be su-
perior to milk and comparable to Viaspan, an organ
transplant storage medium. Although it is not readily
available, Hank's balanced salt solution is available as
Save-A-Tooth (Life-Assist, Inc., Rancho Cordova, CA),
an emergency tooth-preserving system (Figure 11-19).
Maintaining intact and viable periodontal ligament
cells on the root surface is the single most important fac-
tor in preventing replacement resorption. 53 The presence
18 5
of an intact periodontal ligament inhibits the invasion of
osteoclasts and subsequent osteoblasts.
In cases where an avulsed tooth experiences a pro-
longed extra-alveolar period without an appropriate
storage medium, the clinician can assume that the peri-
odontal ligament is necrotic. In these cases the root
should be treated with sodium fluoride because the in-
corporation of fluoride ions into the cementum pro-
duces a tissue more resistant to resorption. 54 The tooth
can be placed in sodium fluoride for 20 minutes before
replantation. Because the presence of a necrotic peri-
odontal ligament retards the resorptive process, it
should not be removed after prolonged periods of ex-
traoral dry time. 55
Although much attention has been given to managing
the avulsed tooth, the socket also appears to play a role
in the prognosis for maintenance of the avulsed tooth . 56
Teeth maintained in an appropriate storage medium had
more resorption as the time out of the socket increased . 57
Before replantation the clinician should inspect the
socket for alveolar fractures and take care not to curette
the socket. If a blood clot is present, removal of the co-
agulum should be accomplished by irrigation with ster-
ile saline. Because removal of the coagulum does not ap-
pear to affect the prognosis, the clinician should not risk
damaging the remaining periodontal ligament fibers and
osseous tissues by attempting to remove the entire clot. 58
Splinting of the avulsed tooth is designed to immo-
bilize the tooth during the healing process. Because the
injury primarily involves the connective tissues of the
periodontal ligament, hygienic and passive splinting
186 Color Atlas o f Endodontics
techniques that permit physiologic movement are advo-
cated to permit regeneration of the attachment appara-
tus. Although rigid splinting increases the incidence of
resorption (as does prolonged splinting), the type of
splint does not seem to be as crucial as the maintenance
of a short splinting period. 59-61
The use of a monofilament nylon fishing line or a
0.015- or 0.030-mm orthodontic wire with acid-etch
composite permits placement of a passive splint that al-
l ows for physiologic movement.62,63 An additional tech-
nique employs bonded orthodontic brackets and an or-
thodontic wire. If a fracture of the alveolar process
occurs in conjunction with avulsion, a more rigid splint
should be used for 4 to 6 weeks.
In teeth exhibiting immature apical development,
revascularization may occur if the tooth is replanted
within 3 hours. Endodontic treatment is not required un-
less signs and symptoms of necrosis are present. Patients
with teeth exhibiting immature apical development
should be followed weekly for the first 4 weeks and then
monthly to evaluate continued root formation and pulp
necrosis. Pulp testing is of questionable value in these
cases because of the type of injury. Moreover, teeth with
i mmature apical development do not always respond to
pulp testing. In addition, canal obliteration, which is a
common occurrence with revascularization, may give a
false negative test result. If necrosis occurs, apexification
procedures are indicated if the tooth is to be maintained.
Revascularization is rare in teeth with complete root
formation, and therefore endodontic treatment is indi-
cated. Periradicular inflammation occurs when the pulp
tissue is not removed. 64 Inflammation results when bac-
teria and toxic tissue by-products enter the periodontal
ligament through the apical foramen and dentinal
tubules that communicate with resorptive defects on the
surface of the root. Early root canal intervention and re-
moval of the necrotic pulp prevent this process.
Endodontic treatment should not be initiated at the
ti me of replantation. It delays replacement of the tooth
in the socket and may damage or contaminate the root
surface. Root canal treatment should only be initiated af-
ter initial healing takes place. Pulp extirpation at 7 to 14
days is adequate to prevent periapical inflammation and
resorption. 64 Endodontic procedures should be per-
formed before splint removal when possible. Rubber dam
isolation is achieved by clamping adjacent healthy teeth.
The placement of calcium hydroxide is indicated after ini-
tial healing. Calcium hydroxide placement at the replan-
tation visit is contraindicated because of the increased in-
cidence of replacement resorption. 65 After performing
complete cleaning and shaping procedures, the clinician
can place calcium hydroxide powder or paste. Barium
sulfate can be added to give radiopacity to the material.
The powder can be placed in the canal with a Messing
gun (Produits Dentaires, S.A., Vevey, Switzerland) and
packed with pluggers. Proprietary injectable calcium hy-
droxide-containing pastes are easy to use and convenient.
An interim restoration is placed and the calcium hydrox-
ide left in place for 2 weeks. Evidence suggests that long-
term use of calcium hydroxide does not enhance the
prognosis. 16,67 Obturation of the canal can be accom-
plished after short-term calcium hydroxide treatment,
usually within 7 to 14 days. This is especially important
for the treatment of patients who are not compliant.
Although long-term use of calcium hydroxide is not
effective in preventing inflammatory resorption, it is ef-
fective in treating the process. 68 If inflammatory resorp
tion is evident, calcium hydroxide should be placed for 6
to 24 months. 69
Treatment Sequence for Avulsion
The following treatment plan should be followed for
teeth with complete apical development that are placed
i n an acceptable transport medium (e.g., Hank's bal-
anced salt solution, milk, saline solution, saliva) or those
that have had less than 2 hours of dry extraoral time:
1. Replant immediately.
2. Splint for 7 to 10 days.
3. Initiate root canal treatment within 7 to 14 days.
4. Place calcium hydroxide for 7 to 14 days.
5. Obturate with gutta-percha.
The following treatment plan should be followed for
teeth that have had more than 2 hours of dry extraoral
ti me:
1. Soak in topical fluoride for 5 to 20 minutes, rinse
with saline, and replant.
2. Perform either intraoral or extraoral root canal
treatment (if extraoral treatment is selected, avoid
chemical or mechanical damage to root).
3. Splint for 7 to 10 days.
4. Place calcium hydroxide for 7 to 14 days if en-
dodontic treatment is intraoral.
5. Obturate with gutta-percha.
The following treatment plan should be followed for
teeth with immature root formation that have had less
than 3 hours of dry extraoral time:
1. Splint.
2. Remove the splint in 7 to 14 days.
3. Perform a weekly evaluation for signs of pulpal
necrosis.
4. If revascularization occurs, perform a 6-month re-
call evaluation.
5. If the pulp does not revascularize, debride the canal,
provide calcium hydroxide therapy, and perform
3-month recall evaluations (apexification).
 Chapter Eleven Traumatic Injuries to the Permanent Dentition
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18 7
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radiographic and histologic study of 50 cases, J Oral Surg 25:414,
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ical and radiographic follow-up study of 189 injured teeth, Scand
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matic injuries to the teeth, ed 3, St Louis, 1994, Mosby.
39. Cvek M; Prognosis of l uxated non-vital maxillary incisors
treated with calcium hydroxide and filled with gutta-percha. A
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40. Andreasen JO: A time related study of root resorption activity af-
ter replantation of mature permanent incisors in monkeys, Swed
Dent) 4:101, 1980.
41. Andreasen JO: Treatment of fractured and avulsed teeth, ASDC J
Dent Child 38:29, 1971.
42. Andreasen JO: Relationship between cell damage in the periodon-
tal ligament after replantation and subsequent development of
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Scand 39:15, 1981.
43. Andreasen JO: Relationship between surface and inflammatory re-
sorption and changes in the pulp after replantation of permanent
incisors in monkeys, J Endodon 7:294, 1981.
44. Andreasen JO et al: Replantation of 400 avulsed permanent in-
cisors. 2. Factors related to pulpal healing, Endod Dent Trauma-
tol 11:59, 1995.
45. Andreasen JO, Hjorting-Hansen E: Replantation of teeth. I. Ra-
diographic and clinical study of 110 human teeth replanted after
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46. Andreasen JO, Kristerson L: The effect of limited drying or re-
moval of the periodontal ligament. Periodontal healing after re-
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tol Scand 39:1, 1981.
47. Blomlof L et a1: Periodontal healing of replanted monkey teeth
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48. Andreasen JO et al: Replantation of 400 avulsed permanent in-
cisors. 4. Factors related to periodontal ligament healing, Endod
Dent Traumatol 11:76, 1995.
18 8 Color Atlas
49. Andreasen JO: Effect of extra-alveolar period and storage media
upon periodontal and pulpal healing after replantation of mature
permanent incisors in monkeys, Int J Oral Surg 10:43, 1981.
50. Blomlof L et al: Storage of experimentally avulsed teeth in milk
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51. Krasner P, Person P: Preserving avulsed teeth for replantation,
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52. Trope M, Friedman S: Periodontal healing of replanted dog teeth
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53. Andreasen JO: Relationship between cell damage in the periodon-
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root resorption. A time-related study in monkeys, Acta Odontol
Scand 39:15, 1981.
54. Coccia CT. A clinical investigation of root resorption rates in reim-
planted young permanent incisors: a five year study, J Endodon
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55. Loe H, Warhaug J: Experimental replantation of teeth in dogs and
monkeys, Arch Oral Biol 3:176, 1961.
56. Morris ML et al: Factors affecting healing after experimentally de-
layed tooth transplantation, J Endodon 7:80, 1981.
57. Trope M, Hupp JG, Mesaros SV: The role of the socket in the
periodontal healing of replanted dogs' teeth stored in Viaspan for
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58. Andreasen JO: The effect of removal of the coagulum in the alve-
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replantation of permanent incisors in monkeys, Acta Odontol
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o f Endodontics
60. Nasjleti CE et al: The effects of different splinting times on re-
plantation of teeth in monkeys, Oral Surg Oral Med Oral Path
Oral Radiol Endod 53:557, 1982.
61. Berude JA et al: Resorption after physiologic and rigid splinting
of replanted permanent incisors in monkeys, J Endodon 14:592,
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62. Antrim DD, Ostrowski JS: A functional splint for traumatized
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63. Oikarinen K: Comparison of the flexibility of various splinting
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North Am 39:93, 1995.
TEB SINA CHEHR (4070932 - 6418770)
19 0 Color Atlas of Endodontics
indicated, the results of that consultation should be
recorded.
2. The patient's chief complaint and dental history
should be reviewed and recorded in his or her own
words. Analysis and evaluation of previous treat-
ment records and radiographs should be noted.
3. An extraoral examination should be conducted and
the results, including medical and dental referrals,
should be recorded.
4. An intraoral examination should be conducted and
the results, including medical and dental referrals,
should be recorded.
5. An examination of the affected tooth or teeth should
be completed. Both subjective and objective tests
should be completed and recorded. If necessary, a
timely referral to a dental specialist may be indicated
and recorded.
6. Current radiographs of diagnostic quality should be
made and interpreted. The radiographs provide in-
formation regarding the particular tooth or teeth
and allow the clinician to make and record observa-
tions regarding the periradicular structures. Again, a
ti mely referral to a dental specialist may be indicated
and recorded.
7. A periodontal examination should be conducted and
the results, including dental specialty recommenda-
tions and medical referrals, should be recorded.
8. Based on the systematic evaluation of the examina-
tion results, a pulpal and periapical diagnosis should
be ascertained and recorded.
9. A proposed treatment plan and options presented to
the patient should be recorded. This record should
include the prognosis for treatment.
10. Informed consent should be obtained and included
in the patient's treatment record. A written docu-
ment is preferred to oral consent.
11. The treatment rendered, including any medications
prescribed, should be detailed in the patient treat-
ment record.
12. A statement indicating that postoperative instruc-
tions and requirements for future visits were re-
viewed with the patient or legal guardian should be
included in the record.
13. The provider should always sign the record.
In addition to the importance of providing a com-
plete and accurate account of treatment provided to pa-
tients, written dental records should be maintained with
the following recommendations in mind:
1. Clinicians should know their state mandates regard-
ing record keeping and retention of dental records as
defined in each state's Dental Practice Act.
2. Entries may become public record. Therefore subjec-
tive commentary is inappropriate. Financial details
should not be listed with the chronologic record of
treatment. In addition, documentation of conversa-
tions with attorneys and insurance carriers has no
place in the treatment record.
3. Always keep the original record, radiographs, con-
sultation reports, and any other documents related to
patient care.
4. All records should be typed or written in black or
blue ink.
S. All records must be legible.
6. Avoid using abbreviations or codes that are not gen-
erally accepted in the profession.
7. Never destroy a record, rewrite information, or use
correction fluid or paper. The mere appearance of
alteration of the record creates an aura of impro-
priety. If an entry must be corrected, put a single
line through the unwanted verbiage and continue
recording the findings. If information is inadver-
tently left out of the treatment record, make an ad-
ditional entry entitled Addendum. The addendum
should be signed and reflect the date the data were
entered.
8. Ensure that patients sign and date informed consent
documents for every procedure.
In addition to the requirement of maintaining accu-
rate treatment records, dentists have a legal obligation
to review the diagnosis and treatment options with their
patients and obtain informed consent to continue with
or refuse endodontic treatment.
I NFORMED CONSENT
The doctrine of informed consent is based on the legal
maxim that every human being of adult years and sound
mind has a right to determine what shall be done with
his or her own body. A provider who performs a proce-
dure without the consent of the patient commits an as-
sault and incurs liability. The informed consent docu-
ment is an agreement by the patient, after full disclosure
of facts needed to make an informed and intelligent de-
cision, to allow a specific treatment to be performed. The
courts have established that providers have a duty to dis-
close information that a reasonably prudent practitioner
would disclose to patients regarding any grave risks of
injury resulting from a proposed course of treatment.'
Moreover, the courts clearly state that health care
providers, as an "integral part" of their responsibilities
to their patients, have a duty of reasonable disclosure re-
garding available alternatives to proposed treatment op-
tions as well as the potential complications inherent in
each treatment option. 2
With respect to informed consent regarding en-
dodontic care provided to a patient, the American Asso-
ciation of Endodontists (AAE) is consistent with the
courts in its recommendations. As a general rule, the
AAE advises that the informed consent requirement is
 Chapter Twelve Legal Considerations in Endodontic Treatment
fulfilled after the practitioner "has discussed with his or
her patient all relevant information so as to assist the pa-
tient in making an informed decision with respect to un-
dergoing that proposed procedure."'
As a general rule the information presented to a pa-
tient must be presented in terminology that can be easily
understood. At the very least, the written informed con-
sent should include the following 3 :
1. The date the informed consent document was
presented and signed by the patient or legal
guardian
2. The diagnosis for each tooth involved, including
both a pulpal and a periapical component
3. A description of the treatment recommended
4. A review of potential complications and postoper-
ative risks associated with the proposed treatments
5. The prognosis regarding the success of each of
the treatment options
6. Alternative treatment options, including no
treatment or extraction
7. A review of potential complications associated
with proposed alternative treatment options
8. The prognosis regarding the success of alterna-
tive treatment options
9. A general acknowledgment that the patient or le-
gal guardian was given an opportunity to ask
questions and that all questions were answered
to the patient's or legal guardian's satisfaction
10. Signature and date spaces for the patient or le-
gal guardian to sign
No specific form can be used for every case. Further-
more, each practitioner should develop an informed con-
sent form that is consistent with the requirements out-
lined in their individual state's Dental Practice Act. The
AAE has developed a sample written informed consent
that is to be used solely as an example; it is not to be
considered a standard or accepted example of a written
informed consent for every state (Figure 12-1). More-
over, the use of a written informed consent form in no
way substitutes for a personal review by the practitioner
of proposed treatment options or alternatives, including
their potential risks.
ABANDONMENT
By initiating endodontic treatment, the dentist has ac-
cepted the legal responsibility to follow the case to com-
pletion or until the case can be referred to a specialist.
This responsibility includes not only completing en-
dodontic therapy, but also being available for subsequent
inter-appointment and postoperative emergency care. If
the dentist fails to comply with his or her obligations to
complete treatment and provide adequate emergency
care, he or she is exposed to liability on the grounds of
abandonment. Therefore the treating dentist should al-
1 91
ways have adequate ways for a patient to access him or
her in the event of an after-hours emergency.
This is not to say that the treating practitioner does
not have the power to sever the doctor/patient relation-
ship unilaterally. A treating dentist may have various rea-
sons for wanting to end his or her treatment obligations
with a particular patient. The dentist may argue that the
patient failed to cooperate with recommended dental care,
failed to keep appointments, or failed to meet financial
obligations. Regardless of the justification for treatment
cessation, a dentist who fails to follow the proper proce-
dures may incur liability for abandonment litigation.
The best defense to an abandonment claim is prepa-
ration based on the concept of reasonable notice. Suc-
cessful endodontic care is based on mutual trust between
the treating dentist and the patient. The treating dentist
should have a prepared procedural template to dismiss a
patient unilaterally from the practice in situations in
which this trust has been compromised.
The clinician should take into account the following
considerations when developing a letter to provide rea-
sonable notice of termination of endodontic care for a
particular patient. Termination should only be consid-
ered if no immediate threat to the patient's dental or sub-
sequent medical health is evident.
1. The letter should be firm, clearly stating the dentist's
plan to terminate the professional relationship.
2. The letter should detail the reasons for the proposed
severance. For example, if the patient has failed to
keep scheduled treatment appointments, the letter
should include the dates of the missed appointments.
3. The clinician should volunteer to provide copies of
the treatment record and the appropriate radiographs
to the new endodontic care provider.
4. The clinician should allow the patient a reasonable
ti me to locate a new practitioner. Reasonable time
may be influenced by different factors. For instance, a
reasonable time in a heavily populated metropolitan
area with an abundance of dental care practitioners
may be less than a reasonable time in a rural or se-
cluded area with a limited number of dentists.
5. The clinician should volunteer to provide emergency
care limited to the treatment already provided while
the patient locates a new provider.
6. The letter should provide an opportunity for the pa-
tient to respond. The clinician should specify a tele-
phone number and a contact person (either the pro-
viding dentist or an office employee).
7. The letter should be sent by certified mail with return
receipt requested.
SUMMARY
Clearly, the best defense against litigation associated
with endodontic treatment is adequate preparation.
 American Association of Endodontists
Informed Consent Guidelines
In today's volatile professional liability environment, litigation
involving informed consent issues is more common than ever.
Corresponding to the increase in litigation is a similar increase
in the rate of malpractice premiums.
While the endodontist may conform to applicable standards
of care in the performance of his or her procedures, that alone
will not prevent him or her from being subjected to a claim by
the patient for an untoward result. Failure to inform the patient
of the risk of an untoward result prior to the performance of
that procedure will just as likely result in a claim by the patient
for failing to obtain his or her consent.
As a general rule, informed consent is satisfied after the
endodontist has discussed with his or her patient all relevant
information so as to assist the patient in making an informed
decision with respect to undergoing that proposed procedure.
History
Informed consent originally developed from common law
principles of negligent non-disclosure. It has since evolved
from repeated interpretations by the courts and state
legislatures into the patient's right to participate in the
decision-making process regarding the type of treatment he or
she is about to undergo. Because of the confusion created by
various interpretations of the doctrine of informed consent by
the courts and state legislatures, it is difficult to formulate a
single, simple statement on the legal requirements of informed
consent.
General guidelines
Despite these various interpretations of informed consent, it is
generally accepted that to obtain the informed consent of the
patient, the endodontist needs to:
I . Disclose the following information in understandable lay
language:
• Diagnosis of the existing problem
• Nature of the proposed treatment or procedure
• Inherent risks associated with the proposed treatment
or procedure
• Prognosis
• Feasible alternatives to the proposed treatment or
procedure
• Inherent risks associated with the alternative
treatments or procedures
• Prognosis of alternative treatments or procedures
2. Provide a generalized opportunity to question the doctor
about any of the above.
Diagnosis
It is required before treatment is rendered that there be a
diagnosis of the existing condition and that this diagnosis be
given in a manner that is readily understood by the patient.
Keep in mind that choosing no treatment at all is always an
alternative to every treatment or procedure. However, the
likely results of no treatment must also be explained.
FIGURE 12-1 AAE sample informed consent form. (Courtesy of the American Association of En-
dodontists, Chicago, IL.)
Lay language
It is important to note that the discussion regarding the
proposed procedure and alternatives and their prognoses must
be presented in language and terms understandable by each
individual patient.
Doctor must discuss
The practitioner who is to perform the procedure must
personally present the details of the case, and the patient must
be able to question the provider regarding treatment or
alternatives. The office staff does not have the power to obtain
consent. A written consent form, while imperative for
accurate record keeping, CANNOT be used as a substitute
for the doctor's discussion with each individual patient.
A thoughtful, well documented dialogue between the doctor
and the patient can reduce misunderstandings and incidence
of claims and suits alleging a lack of informed consent.
Signatures
Your consent form must be signed and dated by the patient
(legal guardian if under 18 years of age) and should be signed
and dated by the practitioner as testimony to the fact that the
endodontist did discuss the elements of the consent form. The
signature of a witness is also recommended.
Consent is limited to procedures discussed
It is important to note that consent is limited to the
procedures discussed and is not open ended. Therefore,
informed consent should be thought of as an ongoing process
that may have to be modified if procedures change (i.e.,
nonsurgical to surgical, unexpected results, or procedural
mishaps).
Designing a form
The form should:
• Document the date and time of the consent process
• Include a statement that the patient was given the
opportunity to question the provider regarding treatment
or alternatives
• Provide space for signatures by the patient, parent or
guardian, the provider, and a witness.
It should be clearly understood that no particular form could
possibly be suggested for use on a uniform basis.The form
provided is a sample and should not be considered a standard
form.
Consult with an attorney and check your state
statutes
These guidelines are not to be considered legal advice.
Members should consider their own particular needs and on
the basis of those needs, draft forms and procedures for use in
their own offices.
Recognizing that state statutes regarding informed consent
vary, it is recommended that members consult their state
statutes when developing their own informed consent forms. A
copy of your state statute can be obtained from your attorney
or by writing to the local county bar association where you
practice or reside.
FIGURE 12-1, cont'd For legend, see opposite page.
1 94 Color Atlas of Endodontics
Practitioners have an obligation to practice within the
guidelines established by the Dental Practice Acts of their
particular states. Copies of particular Dental Practice
Acts can be obtained from the individual State Board of
Dental Examiners or the local dental society. The infor-
mation provided in this chapter is not intended to pro-
vide legal advice or substitute for legal counsel. In fact,
every practitioner who develops written and procedural
record templates is strongly encouraged to seek legal
counsel regarding record-keeping policies, preparation
of informed consent forms, and abandonment issues.
The dental record is the eyewitness in any litigation pro-
ceedings a dentist may face.
References
1. Ze Bartb v Swedish Hospital Medical Center, 81 Wash 2d 12, 499
P.2d 1, 8.
2. Cobbs v Grant, 8 Cal 3d 229, 502 P.2d 1, 104 Ca1.Rptr. 505.
3. American Association of Endodontists: Informed consent guide-
lines, Chicago, American Association of Endodontists.
TEB SINA CHEHR
(4070932 - 6418770)
1 96 Index

Bard-Parker blade, 113 Canines

Barium sulfate, 186 mandibular, endodontic access and, 31, 32f
Basic tray set-up, endodontic surgery and, 151-153, maxillary, endodontic access and, 23, 23f, 24f
152f, 153f Capping, pulp, 169
Beaver bur, 17f Carbon dioxide (CO2), cold testing and, 3, 3f
Beta modification of gutta-percha, 104 Carbon fiber posts, 135f, 138
Bicuspidization, 162 Caries
Blades, microsurgical, 152f complications and, endodontic access and, 41-43,
Blood flow to oral mucosa and skin, 151t 41f
BOMM rule. See Buccal Object Moves Most (BOMM) extensive, 162f
rule. Caries excavation in diagnosis of pulpal and periradic-
Bone healing, root fractures and, 173-176, 176f ular pathosis, 8
Bone wax, 153f, 161 Carrier-based gutta-percha, obturation and, 112-113,
BOR. See Buccal object rule (BOR). 112f
Bowling pin DB, 36f Cast post and core, 132f, 134t, 140, 142f
Brassler H34L bur, 17f Cavi-Endo, 92
Broken instruments, canal filling materials and, 121b Cavitation, acoustic microstreaming and, 93-96, 93f,
Bubble trail, sodium hypochlorite and, 120 94f, 95b, 95f, 96f
Buccal Object Moves Most (BOMM) rule, 55 Cavity, test, in diagnosis of pulpal and periradicular
Buccal object rule (BOR), 55-56 pathosis, 6, 6f
Bupivacaine, 153 CCD. See Charged coupled device (CCD).
Bur-cutting directions, 120f Cement, resinous, post cementation and, 146
Burs Cementation
diamond. See Diamond burs. i nstrumentation stress during, 146
fissure, 15, 15f post, 140, 145-146, 145f, 146f
Mueller, 16-18, 17f Central giant cell granuloma, 156f
round diamond, 15, 15f Ceramic posts, 134t, 135f, 139
surgical length, 16 Chamber, unroofing, endodontic access and, 14
Chamber floor, regaining access to, 119-120, 120b,
C 120f, 121b
Calcific healing, root fractures and, 173 Chamber-retained amalgam, 138
Calcification, canal preparation and, 70 Charged coupled device (CCD), 57-58
Calcified canals, complications and, 43, 45f Chlorhexidine, 155, 162
Calcium hydroxide (CaOH), 113, 128, 169, 171, Chloroform, 106, 106f, 124, 125, 127
180,186 Chronic apical periodontitis, 10
Calcium hyroxide sealers, 102 Chronic periradicular abscess, 10
Calcium sulfate, 153f, 161 Chronic suppurative apical periodontitis, 10
Canal bed enlargement, 70 Citric acid, 68, 161
Canal curvature, canal preparation and, 69f, 70 Clark's rule, 55
Canal filling materials, 121b Cleaning, canal preparation and, 67-74
Canal orifice flaring instruments, 18, 19f Clinical examination
Canal patterns in molars, 37-39 in diagnosis of pulpal and periradicular pathosis, 2,
Canal preparation, 67-77, 75f 3f
cleaning and shaping, 67-74 traumatic injuries to permanent dentition and, 167
clinical significance, 74-75 CO2. See Carbon dioxide (CO2).
evaluation of canal preparation techniques, 74 Cold testing in diagnosis of pulpal and periradicular
techniques for, 69-74, 69f pathosis, 3-4, 3f, 4f, 5f
Canal size CollaCore, hemostasis and, 161
canal preparation and, 70 CollaTape, 153f, 161
general guidelines for, by tooth group, 85t Complicated crown fractures, 168-171, 170f, 171f
Canals Complications, endodontic access and, 39-47
calcified, complications and, endodontic access and, Composite resin cements, 145
43, 45f Concussion, 177, 178f
difficult-to-locate, complications and, endodontic ac- Condensation
cess and, 43, 45f warm lateral, 106-108, 107f
locating, endodontic access and, 14-15 warm vertical, 108-110, 108f, 109f, 110f
 Index 1 97

Condensing osteitis, 9, 10-11 Dental history in diagnosis of pulpal and periradicular

Cones, silver, removal of, 125-126, 125f, 126f pathosis, 2
Connective tissue healing, root fractures and, 173-176, Dental malpractice, 189
176f Dental Practice Acts, 189, 191, 194
Consent, informed. See Informed consent. Dental treatment records, legal considerations and,
Continuous wave obturation, 110-111, 110f 189-190
Core materials, restoration of endodontically treated Dentin chips, overextension and, 102
tooth and, 138 Dentinal hypersensitivity, 10
Core obturation materials, 103-105, 103b, 103f, Dentinal stimulation, direct, in diagnosis of pulpal and
104f, 105f periradicular pathosis, 6, 6f
Cores, failure of, 135, 136f Dentinocemental Junction (DCJ), 50
Coronal disassembly, retreatment and, 119-120, 120b, Dentition, permanent, traumatic injuries to. See Trau-
120f, 121b matic injuries to permanent dentition.
Coronal fractures, 168, 172f Diagnosis of pulpal and periradicular pathosis, 1-11
Coronal pulp, removal of, endodontic access and, 14 acquiring diagnostic database in, 2-9
Coronal reference point, length determination and, 49, categories of, 9-11
50f Diagnostic testing in diagnosis of pulpal and periradic-
Coronal seal, obturation and, 113 ular pathosis, 2-8
Corono-radicular amalgam foundations, 138-146, Diaket, root end filling and, 161
139f Diamond burs
Corrected working length, 56 round, endodontic access and, 15, 15f
CosmoPost, 138-139 tapered, endodontic access and, 15-16, 16f
Council Dichlorodifluoromethane, cold testing and, 3, 3f
on Dental Materials of American Dental Associa- Difficult-to-locate canals, complications and, 43, 45f
tion, 69 Digital images, manipulation of, 43-47
on Scientific Affairs of American Dental Associa- Digital radiography, 57-58, 57f, 58f, 59f
tion, 69 storage phosphor-based, 58
CPR tips, 18 Digora, 58, 59f
Crown fractures, 168-171 Direct cast post and core pattern, fabrication of, 140-
complicated, 168-171, 170f, 171f 142, 142f, 143f, 144f
uncomplicated, 168, 169f Direct dentinal stimulation in diagnosis of pulpal and
Crown root fractures, 171-173, 173f periradicular pathosis, 6, 6f
Crown-down pressureless technique versus pre- Disinfection, regaining access to apex and, 128
flaring, 72 DO composite, 25f
Crown-down technique, 74, 85, 122 Documentation, traumatic injuries to permanent denti-
Crowns tion and, 168
complications and, endodontic access and, 43, Downpacking, 108-110
44f, 45f Draining sinus tract opposite maxillary right second
existing, advantages and disadvantages of removing, premolar, 159f
120b Dry necrosis, 10
full-coverage, restoration of endodontic access Dummer's classifications of apical canal anatomy, 53f
through, 146 Dye staining in diagnosis of pulpal and periradicular
placement of, 134t pathosis, 8, 8f
provisional post, 144-145
CT ultrasonic tips, 96f E
EDTA. See Ethylenediaminetetraacetic acid (EDTA).
D Ektaspeed, Kodak, 58
DCJ. See Dentinocemental junction (DCJ). Electric pulp test (EPT) in diagnosis of pulpal and peri-
Debridement radicular pathosis, 5-6, 5f
canal preparation and, 67 Electronic apex locators in determination of working
regaining access to apex and, 128 length, 58-63, 60f, 61t-62t, 63f, 63t
Demand type pacemakers, electronic apex locators Enamel infraction, 168
and, 60 Endex, 60, 62
DenOptix, 58, 58f, 59f Endo access bur, 17f
Dental cementation. See Cementation. Endo Z bur, 17f
EndoAnalyzer electronic apex locator, 60f, 61
1 98 Index

Endocator, 60 Esthetic carbon fiber posts, 135f

Endodontic access, 13-47 Estimated working length, 56
canal patterns in molars, 37-39, 40f, 41f Ethyl alcohol, 145
goals of, 13-15 Ethyl chloride, cold testing and, 3
instruments and armamentarium, 15-18, 19f Ethylenediaminetetraacetic acid (EDTA), 68, 103, 128
management of complications of, 39-47 Etidocaine, endodontic surgery and, 153
mandibular canines, 31, 32f Eugenol, 145
mandibular incisors, 30-31, 30f, 31f Examination, clinical. See Clinical examination.
mandibular molars, 35-37, 35f, 36f Excavation, caries, in diagnosis of pulpal and peri-
mandibular premolars, 31-32, 33f, 34f radicular pathosis, 8
maxillary canines, 23, 23f, 24f Existing restorative materials, complications and,
maxillary incisors, 21, 21f, 22f 39-41
maxillary molars, 26-27, 26f, 27f-28f, 29f-30f External oblique ridge of mandible, 151f
maxillary premolars, 23, 24f, 25f External resorptive defects, 9f
refinement of, 96 Extra canal, endodontic access and, 15
regaining, to chamber floor, retreatment and, 119- Extrusive luxation, 177, 179f
120, 120b, 120f, 121b
through full-coverage crowns, restoration of, 146 F
uncomplicated access preparations, 21-37 Fabrication
vision, magnification, and illumination, 20-21 of direct cast post and core pattern, 140-142, 142f,
Endodontic surgery, 149-166 143f, 144f
anatomic and physiologic considerations, 149-151 of indirect cast post and core pattern, 144
anesthesia, 153-154 Facial pain in diagnosis of pulpal and periradicular
armamentarium, 151-153 pathosis, 1, 2
flap design, 154-156 Facilitation of instrument placement, endodontic access
intentional replantation, 165 and, 14
root amputation and hemisection, 162-165 False negative and false positive results, pulp testing
root end resection and root end filling, 156-162 and, 5-6
Endodontically treated tooth FDA. See Food and Drug Administration (FDA).
restoration of. See Restoration of endodontically Ferric sulfate, hemostasis and, 161
treated tooth. Ferrule effect, 136, 137, 137f
role of posts in restoration of, 135 Fiberoptic light, transillumination and, 8
structure of, 132 File-mate stop, 50f
Endodontics Files
canal preparation, 67-77 nickel titanium, rotary canal preparation and, 79-80,
diagnosis of pulpal and periradicular pathosis, 1-11 80f
endodontic access, 13-47 in sonic instruments, 93f
endodontic surgery, 149-166 standardized, versus Gates Glidden drills, 71b
legal considerations in, 189-194 ultrasonic. See Ultrasonic files.
length determination, 49-65 Filling, retreatment and, 129
obturation, 99-115 First Lightspeed to bind (FLSB), 88, 88t
restoration of endodontically treated tooth, 131-147 First molars
retreatment and, 117-130, 118b mandibular, canal patterns in, 39, 39f, 40f
rotary canal preparation, 79-89 maxillary, canal patterns in, 36f, 37, 37f
sonics and ultrasonics in. See Sonics and ultrasonics Fissure burs, endodontic access and, 15, 15f
in endodontics. Flap
traumatic injuries to permanent dentition, 167-188 design of, 154-156, 154f
EndoEze System, 146, 146f intrasulcular, 154f, 155
Endo-M-Bloc stop, 50f mucoperiosteal, 154f
Endometric probes, 49 semilunar, 155-156, 155f, 156f
Endoray 11 film holder, 55, 55f submarginal, 155, 155f
Endosonics, 91, 91f, 92f Flash Dent, 57
Endotec, 107, 107f Flex-R file, 73
Epinephrine, 153-154 FLSB. See First Lightspeed to bind (FLSB).
racemic, 160-161 Food and Drug Administration (FDA), 69, 102
EPT. See Electric pulp test (EPT). Fractured instrument removal, 97
 Index 19 9

Fractures History
coronal, 168, 172f medical, in diagnosis of pulpal and periradicular
crown. See Crown fractures. pathosis, 2
crown root, 171-173, 173f traumatic injuries to permanent dentition and, 167
root, 136f, 168f, 173-177, 174f-175f, 176f Hitachi 3CCD microscopic-mounted video camera, 43
Full-coverage crowns, restoration of endodontic access Horizontal root fractures, 168f, 173, 174f-175f, 176f
through, 146 Horizontal root resection, 163f
Hourglass preparation, 69f
G Hybrid technique, injection of thermoplasticized gutta-
Gag reflex, electronic apex locators and, 58 percha and, 111-112
Gates Glidden burs, 16, 19f Hydrodynamic theory in diagnosis of pulpal and peri-
Gates Glidden drills, 18, 70, 71, 71b, 71f, 72, 72f, 74, radicular pathosis, 4
86, 87-88, 113, 124, 126, 126f, 139, 140, 140t, Hydrogen peroxide, 68
141, 141f Hyperflexible nickel titanium instruments, 14
Gelfoam, hemostasis and, 161 Hypersensitivity, dentinal, 10
Gendex GX-S CCD intraoral sensor, 57f
Gendex GX-S CCD-based digital radiography system,
57, 57f Ibuprofen, pain control and, 162
Geristore, 13 Ice sticks, cold testing and, 3, 4f
Glass ionomers, 102, 113 Illumination, endodontic access and, 20-21, 20f
apexogenesis and, 169 Incisal-cervical dimension, 23f
as core material, 138 Incisors
post cementation and, 145, 146 mandibular, endodontic access and, 30-31, 30f, 31f
Glick instrument, 20f maxillary, endodontic access and, 21, 21f, 22f
Gly-Oxide, 63 Inclined teeth, complications and, endodontic access
Good Manufacturing Practice Regulations, 69 and, 42f, 43
Granuloma, central giant cell, 156f Indirect cast post and core pattern, fabrication of,
Great White bur, 17f 144
Greater palatine foramen, 150f Informed consent, 190-191, 192f-193f
Greater Taper series of instruments, rotary canal prepa- legal considerations and, 190-191, 192f-193f
ration and, 83-86, 83f, 84f, 85t retreatment and, 118-119, 118b, 119b
GT rotary file, 18, 19f, 74 Infraction
Gutta-percha, 104-105, 105t, 106 definition of, 168
carrier-based, 112-113, 112f enamel, 168
overextension of, 101 Ingle, John, 56, 70
preparation of post space and, 136 Injection of thermoplasticized gutta-percha, 111-112,
thermoplasticized, injection of, 111-112, 111f 111f
Gutta-percha carrier devices Injuries, traumatic, to permanent dentition. See Trau-
fractured, removal of, 127 matic injuries to permanent dentition.
removal of, 127, 127b Installation stress during cementation, 146
Gutta-percha core materials, removal of, 124-125 Instruments
broken, canal filling materials and, 121b
H canal orifice flaring, endodontic access and, 18, 19f
Handpiece, slow-speed microsurgical, 152f canal preparation and, 68
Hanging drop appearance of periradicular lesions, 9 endodontic access and, 15-18
Hank's balanced salt solution, 185 endodontic surgery and, 151-153, 152f, 153f
Heat in diagnosis of pulpal and periradicular pathosis, facilitation of placement of, endodontic access and,
4-5, 4f, 5f 14
Hedstrom files, 125, 126 fractured, removal of, 97
Heliosonic file, 93f minimizing of flexure of, endodontic access and, 14
Hemisection, root, 162-165, 162f nickel titanium. See Nickel titanium (NiTi)
Hemodent, 153f instruments.
Hemorrhge, hemostasis and, 153 Profile, 74, 80-88, 81f, 82f, 83f, 84f
Hemostatic agents, 153f for root canal preparation based on canal size and
High-speed handpiece, 152f shape, 85t
Intentional replantation, 164f, 165
20 0 Index

Intermediate restorative material (IRM) Local anesthesia

apexogenesis and, 169 i n diagnosis of pulpal and periradicular pathosis, 8
root end filling and, 161 endodontic surgery and, 153-154
Internal resorptive defects, 9f Luer-Lok syringe, 68
International Standards Organization (ISO), 93, 113 Luxation
Intracoronal reference points in length determination, extrusive, 177, 179f
49 intrusive, 177-180, 180f
Intrasulcular flap lateral, 177, 179f
endodontic surgery and, 154f, 155 Luxation injuries, 177-180
submarginal, 155f
M
triangular, 154f, 155
Intrusive luxation, 177-180, 180f MAE See Master apical file (MAF).
Ionizing radiation, radiographic examination and, 8 Magnification, endodontic access and, 20-21, 20f
Ionomers, glass. See Glass ionomers. Malpositioned and rotated teeth, complications and,
IPS Empress, 139 endodontic access and, 43
IRM. See Intermediate restorative material (IRM). Malpractice, dental, 189
Irreversible pulpitis, 10 Mandibular anterior region of mandible, 150f
Irrigants, canal preparation and, 67-69 Mandibular canines, endodontic access and, 31, 32f
Irrigation Mandibular first molars, canal patterns in, 39, 39f, 40f
canal preparation and, 67-69 Mandibular incisors, endodontic access and, 30-31,
regaining access to apex and, 128 30f, 31f
ISO. See International Standards Organization (ISO). Mandibular inferior alveolar nerve block in diagnosis
of pulpal and periradicular pathosis, 8
J Mandibular molars
Journal o f the American Dental Association, 60 endodontic access and, 35-37, 35f, 36f
first, canal patterns in, 39, 39f, 40f
K root amputation and hemisection and, 163
K-files, 73, 92f, 93f second, canal patterns in, 39, 40f, 41f
K-flex files, 74 Mandibular premolars, 31-32, 33f, 34f
KIS ultrasonic surgery tips, 96f Mandibular radiography, 56
Kodak Ektaspeed, 58 Mandibular second molars, canal patterns in, 39, 40f,
41f
L Manipulation of digital images, endodontic access and,
Lactic acid, 68 43-47
Lateral condensation, obturation and, 105-106, 105f MAR file. See Master apical rotary (MAR) file.
Lateral extrusive luxation injury, 179f Martensite phase, nickel titanium instruments and, 79
Lateral intrusive traumatic injury, 180f Master apical file (MAF), 70
Lateral luxation, 177, 179f, 182f-183f Master apical rotary (MAR) file, 88, 88t
Legal considerations in endodontic treatment, 189-194 Maxillary anterior osseous structures, 150f
abandonment, 191 Maxillary canines, endodontic access and, 23, 23f, 24f
i nformed consent, 190-191, 192f-193f Maxillary first molars, canal patterns in, 36f, 37, 37f
treatment records, 189-190 Maxillary incisors, endodontic access and, 21, 21f, 22f
Length determination, 49-65 Maxillary molars
apical reference point, 50-54 endodontic access and, 26-27, 26f, 27f-28f, 29f-30f
coronal reference point, 49, 50f first, canal patterns in, 36f, 37, 37f
methods of determining working length, 54-63 root amputation and hemisection and, 163
Lentulo spiral, post cementation and, 140 second, canal patterns in, 37, 37f, 38f
Liability, lack of informed consent and, 190 Maxillary posterior region, 150f
Lidocaine, hemostasis and, 153 Maxillary premolars
Lightspeed nickel titanium instruments, 86, 87-88, 87f, access for, 24f
88t endodontic access and, 23, 24f, 25f
Lightspeed rotary instruments, 74 Maxillary second molars, canal patterns in, 37, 37f,
Limited opening, endodontic access and, 43 38f
d-Limonene, 125 MB2 canal. See Mesiobuccal (MB2 ) canal.
Liquefactive necrosis, 10 Medical history in diagnosis of pulpal and periradicu-
lar pathosis, 2
 Index 20 1

Mental foramen, 151f Normal periradicular status of teeth, 10

Mesiobuccal ( MB2 ) canal, 26f, 28f, 29f, 36f, 37f, 38f, Normal pulpal status of teeth, 9
56 Nugauze, 153f
Mesiodistal fracture, 20f
Messing gun, 152f, 186 O
Metal cutters, endodontic access and, 16, 17f Obtura instrument, 110, 110f, 111
Methylene blue, 156, 160 Obturation, 99-115, 101f, 102f
Micro-Etcher, 145, 145f continuous wave, 110-111, 110f
Microleakage, preparation of post space as relates to, coronal seal, 113
136, 137f obturating materials, 102-105
Microscopes, 13, 20-21, 20f removal of smear layer before, 102-103
Microspheres, radiolabeled, blood flow measured by, techniques of, 105-113
151t when to carry out, 113
Microstreaming, acoustic, cavitation and, 93-96, 93f, Obturation material, ideal properties of, 103b
94f, 95b, 95f, 96f Oral hygiene instructions, 162
Microsurgical blades, 152f Oral mucosa, blood flow to, 151t
Microsurgical handpiece, slow-speed, 152f Orifice shapers, 18, 19f
Microsurgical mirrors, 152f Orofacial pain in diagnosis of pulpal and periradicular
Milk as storage medium for teeth, 185 pathosis, 1, 2
Miller Index of Tooth Mobility, 7 Orthodontic considerations, retreatment and, 119b
Mineral trioxide aggregate (MTA), 13, 102, 153f, 161, Oscillation of ultrasonic files, 91-92, 91f, 92f
169 Osteitis, condensing, 9, 10-11
Minimizing of instrument flexure, endodontic access Overextension
and, 14 i njection of thermoplasticized gutta-percha and, III-
Mirrors, microsurgical, 152f 112
Mobility in diagnosis of pulpal and periradicular versus overfilling, 100-102, 101f
pathosis, 7 Overfilling versus overextension, 100-102, 101f
Modifications for NiTi rotary instruments, endodontic
access and, 43, 46f P
Modified paralleling technique, 55 Pacemakers, electronic apex locators and, 60
Molars Pain in diagnosis of pulpal and periradicular pathosis, 2
canal patterns in, endodontic access and, 37-39 Palpation in diagnosis of pulpal and periradicular
mandibular. See Mandibular molars. pathosis, 6-7, 7f
maxillary. See Maxillary molars. Panavia 21, 140
Mouth mirror, 152f Paraformaldehyde, 102, 104
MTA. See Mineral trioxide aggregate (MTA). ParaPost, 139, 140, 141f
Mucoperiosteal flap, 154f ParaPost XP post, 140, 141, 144
Mueller burs, endodontic access and, 16-18, 17f ParaPost X drills, 140, 141f
Multipurpose bur, 17f Passive prefabricated posts, 138
Passive step-back technique for canal preparation, 72
N Paste filling, removal of, 124, 124b
Narcotic analgesics, pain control and, 162 Pastes
Necrosis, pulp, 2, 9, 10 canal filling materials and, 121b
Nickel titanium (NiTi) core materials, removal of, 127- as core obturation materials, 103-104
128 Pathosis, pulpal and periradicular, diagnosis of, 1-11
Nickel titanium (NiTi) files, 80 PDL injection. See Periodontal ligament (PDL)
Nickel titanium (NiTi) instruments, 14, 21, 22f injection.
for canal preparation, 74 Peet's forceps, 127
fractured, 97 Penetrators, endodontic access and, 16, 17f
removal of, 127 Percussion in diagnosis of pulpal and periradicular
rotary, modifications for, 43, 46f pathosis, 6, 6f, 7f
rotary canal preparation and, 79-80, 80f Periapical radiographs, 9
Nickel titanium (NiTi) spreaders, 106 Periodontal considerations, retreatment and, 119b
NiTi. See Nickel titanium (NiTi). Periodontal healing, avulsion and, 183
Non-eugenol cement, 145 Periodontal ligament (PDL) injection in diagnosis of
Nonstandardized gutta-percha cones, 105, 105f pulpal and periradicular pathosis, 8
202 Index

Periodontal probing in diagnosis of pulpal and peri- Prepi bur, 113

radicular pathosis, 7-8, 7f Previous treatment, canal preparation and, 70
Periodontal reactions to avulsion, 180-183, 182f-183f Pro Root, 161
Periodontitis, 10 Probing, periodontal, in diagnosis of pulpal and peri-
Periradicular abscess, 10 radicular pathosis, 7-8, 7f
Periradicular pathosis, diagnosis of, 1-11 Profile .02, .04, and .06 tapered instruments, 81, 81f,
Permanent dentition, traumatic injuries to. See Trau- 82f
matic injuries to permanent dentition. Profile 29 series of instruments, 80-81
Phoenix abscess, 10 Profile instruments, 74, 80-88, 81f, 82f, 83f, 84f
Phosphoric acid gel, post cementation and, 145 Prognosis, retreatment and, 129
Physiologic considerations, endodontic surgery and, ProPost drills, 113
149-151, 150f, 151f, 151t ProRoot, 153f
PID. See Position indicating device (PID). Prosthetic considerations, retreatment and, 119b
Planning, retreatment and, 118-119, 118b, 119b ProSystem GT files, 83, 85, 86
Plastic core materials, removal of, 127 Provisional post crown, 144-145
Plug silver point device, 125 Pulp, coronal, removal of, endodontic access and, 14
Polyisoprene, 104 Pulp capping, 169
Polysulfone polymer, 113 Pulp necrosis, 2, 9, 10, 157f
Polyvinylsiloxane putty matrix, 145 Pulp testing
Position indicating device (PID), 58 in diagnosis of pulpal and periradicular pathosis, 2-6
Positive stop features, post and core restorations and, electric, 5-6
136 Pulpal and periradicular pathosis, diagnosis of, 1-11
Post and core foundations, cast, 132f, 142f Pulpal reactions to avulsion, 183, 184f
Post and core pattern Pulpitis
direct cast, fabrication of, 140-142, 142f, 143f, 144f irreversible, 10
indirect cast, fabrication of, 144 reversible, 2, 9-10
Post removal Pulpotomy, 169
devices for, 122f, 123f
retreatment and, 120-122, 121f, 122f, 123f Q
Post space, preparation of, as relates to apical seal and Quantec Flare, 87
microleakage, 136, 137f Quantec series of instruments, rotary canal preparation
Posterior teeth, endodontically treated, restoration of, and, 86-87, 86f, 87f
132-135
R
Posts
cementation of, 145-146, 145f, 146f Racellets, 160-161
failure of, 135, 136f Racemic epinephrine, 160-161
isolated using ultrasonics, 120f Radiation, ionizing, radiographic examination and, 8
prefabricated, restoration of endodontically treated Radicular filling material or obstructions, removal of,
tooth and, 138-140, 139f, 140t, 141f 122-128
role of, in restoration of endodontically treated teeth, Radiographic examination
135 i n determination of working length, 54-56, 55f, 56f,
size and length of, 135-136 57f
titanium, 127, 127b in diagnosis of pulpal and periradicular pathosis,
types of, 135, 135f 8-9, 9f
Posttreatment responsibilities, retreatment and, 129 digital, 57-58, 57f, 58f, 59f
Prefabricated posts mandibular, 56
and amalgam core, 133t periapical, 9
and direct resin core, 133t traumatic injuries to permanent dentition and, 168,
restoration of endodontically treated tooth and, 138- 168f
140, 139f, 140t, 141f Radiographic incrementation, 56
Pre-flaring versus crown-down pressureless technique, Radiolabeled microspheres, blood flow measured by,
72 151t
Preformed post systems, 139f RadioVisioGraphy system, 57
Premolars Reference point
mandibular, endodontic access and, 31-32, 33f, 34f apical, length determination and, 50-54, 50f, 51f, 52f
maxillary. See Maxillary premolars. coronal, length determination and, 49, 50f
 Index 203

Regaining access Retreatment-cont'd

to apex, retreatment and, 128 removal system procedure clinical technique in, 122
to chamber floor, 119-120, 120b, 120f, 121b success and failure in, 117, 118b
Regain Sens-A-Ray, 58 surgical, 129
Reinforced resins as core material, 138 Reversible pulpitis, 2, 9-10
Reinstrumentation, regaining access to apex and, 128 Risk management and prevention, legal considerations
Removal and, 189
of amalgam, 20f Rispisonic files, 92-93, 93f
of coronal pulp, endodontic access and, 14 Roentgen, Wilhelm, 54
of fractured gutta-percha carriers, 127 Root amputation and hemisection, 162-165, 162f
of fractured instruments, 97 Root end filling, endodontic surgery and, 156-162,
of fractured nickel titanium instruments, 127 157f, 158f-159f
of gutta-percha carrier devices, 127, 127b Root end resection, endodontic surgery and, 156-162,
of gutta-percha core materials, 124-125 157f, 158f-159f
of nickel titanium core materials, 127-128 Root fractures, 136f, 168f, 173-177, 174f-175f, 176f
of paste filling, 124, 124b Root length, canal preparation and, 69
of plastic core materials, 127 Root resection, root amputation and hemisection and,
post, 120-122, 121f, 122f, 123f 163-165, 163f
of radicular filling material or obstructions, 122-128 Root surface, treatment of, healing and, 185
Replantation, intentional, 164f, 165 Root width, canal preparation and, 69
Residual pulp in horn, 22f Root ZX, 60-61, 60f, 62
Resin cores, 138 Rotary canal preparation, 79-89
Resin restoration in access opening, 133t nickel titanium files, 79-80
Resin sealers, 102 profile instruments, 80-88
Resinous cement, post cementation and, 146 Rotated and malpositioned teeth, complications and, 43
Resins, reinforced, as core material, 138 Round diamond burs, endodontic access and, 15, 15f
Resorption, canal preparation and, 70 RTLX, 58
Restoration Rubber dam, isolating tooth with, for thermal testing,
canal preparation and, 70 5, 5f
of endodontic access through full-coverage crowns,
146 S
of endodontically treated tooth, 131-147, 132f, Saliva as storage medium for teeth, 185
133t-134t Salt water, 162
preparation and fabrication techniques in, 138- Same Lingual Opposite Buccal (SLOB) rule, 55
146 Sargenti formulation paste, 104f
role of posts in, 135 Save-A-Tooth emergency tooth-preserving system, 185,
treatment goals in, 131 185f
treatment planning in, 131-138 Schick CDR, 57
existing, advantages and disadvantages of removing, Schilder pluggers, 108f
120b Schilder technique, 110
retreatment and, 118-119, 118b, 119b Sealers
Restorative materials, existing, complications and, 39- i deal, properties of, 102b
41 obturation and, 102-103, 102b
Retreatment, 96, 117-130 overextension of, 101
complications and, 43 Seamens Sidexis, 58
coronal disassembly in, 119-120, 121b Second molars
filling, prognosis, and posttreatment responsibilities mandibular, canal patterns in, 39, 40f, 41f
in, 129 maxillary, canal patterns in, 37, 37f, 38f
planning, restoration, and consent in, 118-119 Sectional silver point device, 125
post removal in, 120-122, 123f Selective anesthesia in diagnosis of pulpal and peri-
regaining access to apex in, 128 radicular pathosis, 8
regaining access to chamber floor in, 119-120, 121b Semilunar flap, endodontic surgery and, 155-156,
reinstrumentation, irrigation, debridement, and dis- 155f, 156f
i nfection in, 128 Semisolids
removal of radicular filling material or obstructions canal filling materials and, 121b
in, 122-128 as core obturation materials, 103
204 Index

Sens-A-Ray, 57 Storage phosphor-based digital radiography, 58

Sensitivity Straight line access, canal preparation and, 75f
in diagnosis of pulpal and periradicular pathosis, 1 Streaming, acoustic, 93-96, 94f
thermal, coronal fractures and, 168, 169f Stropko irrigator, 16, 152f
Shaper files, 92-93, 93f Subluxation, 177, 179f
Shaping, canal preparation and, 67-74 Submarginal flap
Shaping files, 85 endodontic surgery and, 155, 155f
Silicone stops, 49, 50f intrasulcular, 155f
Silver cones, 103f Super EBA. See Super ethoxybenzoic acid (Super
with amalgam remnants, 126f EBA).
removal of, 125-126, 125f, 126f Super ethoxybenzoic acid (Super EBA), 153f, 161
SLOB rule. See Same Lingual Opposite Buccal (SLOB) Suppurative apical periodontitis, chronic, 10
rule. Sure-Stop silicone endodontic stop dispenser, 50f
Slow-speed microsurgical handpiece, 152f Surgery
Smear layer, removal of, before obturation, 102-103 apical, use of ultrasound in, 97
Sodium hypochlorite, 68, 124, 136 endodontic. See Endodontic surgery.
Solfy ZX, 62 Surgical extrusion, crown root fractures and, 173
Solids Surgical length burs, endodontic access and, 16
canal filling materials and, 121b Surgical retreatment, 129
as core obturation materials, 103 Surgicel, 161
Solvents SurgiLube, 142
apical modification with, obturation and, 106, 106f, Swelling
107f of buccal and lingual soft tissues, 7f
gutta-percha fillings and, 125 in buccal furcation area of mandible, 158f-159f
removal of paste fillings and, 124 System B, 13, 107, 110-111, 110f
Sonic handpiece, 92f
Sonics and ultrasonics in endodontics, 91-97 T
access refinement, 96 Taper selection for root canal preparation based on
cavitation and acoustic microstreaming, 93-96 canal size and shape, 85t
file design, 92-93 Tapered diamond burs, endodontic access and, 15-16,
fractured instrument removal, 97 16f
oscillation of ultrasonic files, 91-92 Teeth
retreatment, 96 anterior, endodontically treated, restoration of,
use of ultrasound in apical surgery, 97 132-135
Sono-Explorer, 60, 62 crowned, complications and, endodontic access and,
Spartan ultrasonic handpiece, 18f 43, 44f, 45f
Specificity in diagnosis of pulpal and periradicular endodontically treated, restoration of. See Restora-
pathosis, 1 tion of endodontically treated tooth.
Spring-back, gutta-percha fillings and, 125 endodontically treated. See Endodontically treated
Staging, removal of silver cones and, 126-127, 126f tooth.
Staining, dye, in diagnosis of pulpal and periradicular inclined, complications and, endodontic access and,
pathosis, 8, 8f 42f, 43
Stainless steel instruments, fractured, 97 normal, 9
Stainless steel posts, 135f posterior, endodontically treated, restoration of,
Standardized gutta-percha cones, 105, 105f 132-135
State Board of Dental Examiners, 194 rotated and malpositioned, complications and, en-
Steiglitz forceps, 96, 121, 121f, 126, 127 dodontic access and, 43
Step-back instrumentation, canal preparation and, 75f TempBond NE, 145
Step-back technique for canal preparation, 70-71, 70f, Test cavity in diagnosis of pulpal and periradicular
71b, 71f, 72f pathosis, 6, 6f
Step-down technique for canal preparation, 72 Testing
Stimulation, direct dentinal, in diagnosis of pulpal and anesthetic, in diagnosis of pulpal and periradicular
periradicular pathosis, 6, 6f pathosis, 8
Stops diagnostic, in diagnosis of pulpal and periradicular
overextension and, 101f, 102 pathosis, 2-8
Silicone, 49, 50f
 Index 205

Testing-cont'd Ultrasonics
pulp. See Pulp testing. endodontic access and, 18, 18f
thermal, in diagnosis of pulpal and periradicular in nonsurgical root canal preparation, 95b
pathosis, 3-5, 3f, 4f, 5f post isolated using, 120f
Thermafil, 13, 112-113, 112f sonics and. See Sonics and ultrasonics in endodontics.
Thermal sensitivity, coronal fractures and, 168, 169f Ultrasound, use of, in apical surgery, 97
Thermal testing in diagnosis of pulpal and periradicu- Uncomplicated access preparations, 21-37
lar pathosis, 3-5, 3f, 4f, 5f Uncomplicated crown fractures, 168, 169f
Thermoplasticized gutta-percha, injection of, 111-112, Underextension, injection of thermoplasticized gutta-
111f percha and, 111-112
Titanium, nickel and. See Nickel titanium (NiTi) Universal Hand Driver, 140, 141
instruments. Unroofing the chamber, endodontic access and, 14
Titanium posts, 127, 127b
Titanium tips, ultra-slim, 95t V
Tooth. See Teeth. Vacuum-formed polystyrene matrix, 145
Tooth Slooth, 6, 7f Vertical root resection, 163f
Touch `N Heat, 107, 108, 109f Viaspan, 185
Transillumination in diagnosis of pulpal and periradic- Viscostat, 161
ular pathosis, 8, 8f Vision, endodontic access and, 20-21, 20f
Transmetal bur, 17f Visualix Vixa, 58
Traumatic injuries to permanent dentition, 167-188 Voids, gutta-percha and, 106
avulsion, 180-186
clinical examination in assessment of, 167 W
crown fractures, 168-171 Wach's Paste, 113
crown root fractures, 171-173 Walkhoff, Otto, 54
documentation of, 168 Walton's projection, 55
history in assessment of, 167 Warm lateral condensation, 106-108, 107f
luxation injuries, 177-180 Warm vertical condensation, 108-110, 108f, 109f, 110f
radiographic examination in assessment of, 168 Whaledent ParaPost drills, 140t
root fractures, 173-177 White dot connective tissue remnant, Mueller burs and,
Treatment records, legal considerations and, 189-190 16
Tri Auto ZX, 62, 63f White line connective tissue remnant, Mueller burs
Triangular intrasulcular flap, 154f, 155 and, 16
Trophy RVG, 43, 58 Working length, 57f, 105-106
Trophy RVGui, 43 corrected, 56
Troughing cement around post, 121, 121f definition of, 49
Tubliseal, 113 determination of. See Length determination.
Twist-off silver point device, 125, 125f estimated, 56
269GK bur, 17f Written informed consent. See Informed consent.

U Z
Ultra-slim titanium tips, 95t Zap-and-tap technique, 107, 107f
Ultrasonic files Zinc oxide-eugenol sealers, 102
design of, 92-93, 93f Zinc phosphate, 145, 146
oscillation of, 91-92, 91f, 92f Zipping, canal preparation and, 70
Ultrasonic tips, 122f, 152f Zirconium oxide posts, 138-139